Donato v. Metropolitan Life Ins. Co.

• Decision Date: 30 April 1993
• Docket Number: No. 92 C 1242.,92 C 1242.
• Citation: 822 F. Supp. 535
• Parties: Christine M. DONATO, Plaintiff, v. METROPOLITAN LIFE INSURANCE CO., Defendant.
• Court: U.S. District Court — Northern District of Illinois

822 F. Supp. 535

Christine M. DONATO, Plaintiff, v. METROPOLITAN LIFE INSURANCE CO., Defendant.

No. 92 C 1242.

United States District Court, N.D. Illinois, E.D.

April 30, 1993.

Donald V. Young, Chicago, IL, for plaintiff.

Joseph J. Hasman, Ernest W. Irons, Sherri L. Giffin, Chicago, IL, for defendant.

MEMORANDUM OPINION AND ORDER

SHADUR, Senior District Judge.

Christine M. Donato ("Donato"), a former Kemper Financial Services ("Kemper") employee who was initially granted and then later denied disability benefits under Kemper's Long Term Disability Benefit Plan ("Plan"), has filed this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, against Metropolitan Life Insurance Company ("MetLife"), which underwrote the Plan and served as its Claims Administrator. In response to Donato's claim for reinstatement of her benefits, MetLife argues not only that its disavowal of any current obligation to pay benefits was proper but also that it is entitled to a partial rebate of the amount that it had previously paid under its policy.

MetLife has now moved for summary judgment under Fed.R.Civ.P. ("Rule") 56. For the reasons stated in this memorandum opinion and order, its motion is granted.

Background

Rule 56 imposes on the movant the burden of establishing the lack of a genuine issue of material fact (Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 2552, 91 L.Ed.2d 265 (1986)). For that purpose a "genuine" issue does not exist unless record evidence would permit a reasonable factfinder to adopt the nonmovant's view (Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 2510, 91 L.Ed.2d 202 (1986)), and only facts that would prove outcome-determinative under substantive law are "material" (Pritchard v. Rainfair, Inc., 945 F.2d 185, 191 (7th Cir.1991)). In both respects this Court is "not required to draw every conceivable inference from the record —only those inferences that are reasonable" in the light most favorable to the nonmovant (Bank Leumi Le-Israel, B.M. v. Lee, 928 F.2d 232, 236 (7th Cir.1991)).

Summary judgment motions in disability cases such as this one are often particularly suitable for disposition via summary judgment because of the absence of disputed factual issues.¹ Instead the parties typically disagree as to whether those uncontested facts meet the "disability" standard—whether it is a statute (as in Social Security cases) or an employee benefit plan (in ERISA cases such as this one) that sets the standard for the payment of benefits.

In this case the facts as to Donato's physical problems are not controverted. What is in dispute is the significance of those problems as to the existence or nonexistence of a disability under the Plan. Hence the following factual recital speaks briefly of those physical problems, then turns to the medical evaluations that served as the grist for MetLife's decisional mill.

Donato began working at Kemper as a legal secretary in March 1987. By the fall of 1990 she had begun to feel generally fatigued and to suffer from headaches. As time went on her condition worsened, and she began to feel unusually sensitive to such common stimuli as smoke, perfume and carpeting. But as she told Dr. Theron Randolph in 1990, a traditional allergist whom she had seen earlier had not diagnosed her as being afflicted by any allergies (D.Ex. E at 2).²

In consequence of his evaluation based on consultations beginning in October 1990, Dr. Randolph diagnosed Donato as "suffering from an acute susceptibility to environmental chemical exposures" that rendered her unable to work (Randolph Aff. ¶ 3). Dr. Randolph also concluded that continued exposure to common environmental chemicals would be likely to cause continued worsening of Donato's condition (id. ¶ 5).

In February 1991 Donato submitted a claim to MetLife for disability benefits, claiming that a severe allergic reaction to environmental chemicals had disabled her since July 17, 1990. As support she relied on diagnoses by Drs. Randolph and George Shambaugh, Jr.³ In April 1991 MetLife approved Donato's claim effective January 17, 1991 (that date was six months after the claimed onset of the disability, as the Plan specified for long-term disability coverage). MetLife then began making payments to her (D. 12(m) ¶¶ 8-9).

In May 1991 MetLife forwarded Donato's medical records to a medical consulting firm, Underwriting Medical Actuarial Consultants, Inc. ("UMAC"), for review. UMAC initiated review of Donato's file by a board-certified internist and a roundtable including other doctors, one of them an allergist-immunologist. UMAC's May 31, 1991 report ("UMAC I," D.Ex. C) derided the makeup of Donato's evidence as "wordy, confusing, and providing little if any accepted medical information" (id. at 1) and explained its rationale (id. at 2-3):

The therapies and supposition discussed by Donato's doctors are not widely supported by the AMA, the American College of Physicians, or recognized medical bodies.

* * * * * *

The evaluation, tests and diagnoses provided by Drs. Shambaugh and Randolph do not conform to medical standards.

UMAC I concluded "that no disability exists that would prevent this patient from performing the activities of daily living or her duties as a legal secretary" (id. at 3).⁴

In reliance on UMAC I MetLife terminated Donato's benefits. Its August 9, 1991 letter to Donato explained the bases of that decision and advised her as to how she could seek review of the determination.

At Dr. Randolph's recommendation Donato was later (in October 1991) hospitalized for detoxification at the Environmental Health Center in Dallas, Texas. There she entered the care of Dr. Gerald H. Ross, who performed a "blood analysis that confirmed chemical contamination, immune disfunction and ... evidence of toxic brain syndrome" (Ross Aff. ¶ 3). Dr. Ross concurred with Dr. Randolph that Donato was disabled (id. ¶ 4).

After bringing this action early in 1992, Donato submitted further documents (including Dr. Ross' evaluation) for MetLife's review. MetLife in turn forwarded those documents to UMAC for another review. This time a second roundtable of physicians, which again included an allergist/immunologist, issued a report reaching conclusions that were for all effective purposes coterminous with those found in UMAC I (D.Ex. F).

Needless to say, MetLife did not reverse course and reinstate Donato's benefits. This Court, which has jurisdiction of this action pursuant to ERISA and 28 U.S.C. § 1331, now reviews MetLife's decisions.

Standard of Review

At the outset this Court is called upon to determine whether to apply a de novo standard (as Donato urges) or an "arbitrary and capricious" standard (as contended for by MetLife) in reviewing MetLife's denial of benefits. On that score MetLife clearly has the better of the argument.

Because ERISA does not prescribe any specific standard for reviewing a trust administrator's decision, Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 110-11, 109 S.Ct. 948, 953-54, 103 L.Ed.2d 80 (1989) reconfirmed that the standard is to be drawn from trust law. After reviewing the general principles of trust law Bruch, 489 U.S. at 115, 109 S.Ct. at 956 held that when an administrator or fiduciary interprets plan terms, ERISA calls for de novo review of that decision "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan"—an exception that, given the ready ability of administrators to draft plans in that fashion, promises to swallow up the rule itself. And to that end, of course, no magic formulation (such as the necessity to use the word "discretion" itself) is required to grant discretion to an administrator (see Petrilli v. Drechsel, 910 F.2d 1441, 1447 (7th Cir.1990) and cases cited there).

But to return to Bruch, that opinion expressly defined its scope in these terms (489 U.S. at 108, 109 S.Ct. at 952 (emphasis added)):

The discussion which follows is limited to the appropriate standard of review in § 1132(a)(1)(B) actions challenging denials of benefits based on plan interpretations.

Given that self-limitation, it might perhaps be possible to distinguish the scope of review of an administrator's factual decisions (as contrasted with interpretive decisions) as an issue left unresolved by Bruch. As Pierre v. Connecticut Gen. Life Ins. Co., 932 F.2d 1552, 1557 (5th Cir.1991) (citations omitted) put it:

A plan administrator has to make determinations that may be divided into two general categories. First, he must determine the facts underlying the claim for benefits. Second, he must then determine whether those facts constitute a claim to be honored under the terms of the plan. Bruch addressed the proper standard of review that is to be given to the plan administrator's second determination. Bruch did not speak to the first.

Donato seeks to make just such a distinction in urging de novo review of MetLife's decision here.

In those terms the Plan here provides for benefits, after an employee has been "Fully Disabled" for six months, throughout the period of "Full Disability" while the employee remains under doctor's care for that condition. It defines capitalized terms:

"Full Disability" or "Fully Disabled" means that because of a sickness or injury, you can not do your job.

To the extent that a line might arguably be drawn between plan-interpretive and factual decisions, the Pierre distinction is not the only way to make the demarcation. For example, the determination whether an employee has a "sickness" (where that term is left undefined in the Plan) might be viewed as interpretation, while the determination whether the employee "can not do her job" might be viewed as wholly factual.⁵ But it is needless to parse matters any further in that respect. Though MetLife does not dispute the characterization of its decision...