Lindsey v. Metropolitan Life Ins. Co.

• Decision Date: 08 November 1995
• Docket Number: No. 95-CV-037J.,95-CV-037J.
• Parties: Sam LINDSEY, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, a New York corporation, Defendant.
• Court: U.S. District Court — District of Wyoming

909 F. Supp. 1408

Sam LINDSEY, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, a New York corporation, Defendant.

No. 95-CV-037J.

United States District Court, D. Wyoming.

November 8, 1995.

William M. McKellar, Boley & McKellar, Cheyenne, WY, Glenn E. Smith, Glenn E. Smith & Associates, Cheyenne, WY, for Sam Lindsey.

Bradley T. Cave, Edward E. Risha, Holland & Hart, Cheyenne, WY, Michael S. Beaver, Jimmy Goh, Holland & Hart, Denver, CO, for Metropolitan Life Insurance Company, a New York corporation.

ORDER ON MOTIONS FOR SUMMARY JUDGMENT

ALAN B. JOHNSON, Chief Judge.

The plaintiff's Motion for Summary Judgment and the defendant's Motion for Summary Judgment came before the Court for consideration, having been submitted to the Court upon briefs of the parties. The Court, having considered the parties' motions, the memoranda filed in support of the motions as well as all supporting materials offered by the parties, and being fully advised in the premises, FINDS and ORDERS as follows:

Background

Plaintiff claims he is entitled to receive long term disability benefits pursuant to the qualified employee welfare benefit plan established by his former employer, XL/Datacomp, Inc., under the Employee Retirement Income Security Act of 1974 ("ERISA"). The plan at issue was insured through defendant Metropolitan Life Insurance Company ("MetLife"). The plan purchased disability benefits from MetLife as the method of providing the benefits promised under the Plan. MetLife is both the insurer and fiduciary under the plan.

From January 1990 until January 1995, plaintiff was employed by XL/Datacomp, Inc. Throughout the period of his employment with XL/Datacomp, plaintiff was enrolled in the plan as a participant. Consequently, plaintiff was insured for, and was eligible to receive, long term disability benefits from the plan in the event he became disabled to work. Plaintiff asserts that what is required to establish total disability under the plan is proof that (a) the plan participant suffered a 50% loss of earnings capacity because of an injury or sickness and (b) that he, as the plan participant, has required the regular care and attendance of a doctor.

When MetLife receives proof that a plan participant is Totally Disabled, the plan requires MetLife to pay, beginning 180 days after the onset of total disability, a monthly benefit in accordance with the Schedule of Benefits set forth in the plan. That benefit is the lesser of $10,000 per month or 60% of the basic monthly earnings. Plaintiff earned $151,000 in commissions in the 12 months preceding his disability, or $12,583.33 per month. Sixty percent of that monthly sum is $7,550. Since that sum is less than $10,000 per month, plaintiff contends that he is entitled to receive $7,550 per month, from January 27, 1994, and continuing for as long as he remains totally disabled or until age 65, whichever first occurs. See also METLIND at 00015. Both plaintiff and defendant have included portions of the MetLife claim file as exhibits in support of their motions for summary judgment. For convenience, in this Order the Court will refer to exhibits or materials contained in the claim file, whether offered by defendant or plaintiff, as METLIND at ___.

Beginning in 1991, and while employed by XL/Datacomp and while a participant in the plan, plaintiff began to experience serious ongoing medical problems which required extensive medical and surgical treatment, including removal of a kidney and various other treatments. As a result, plaintiff was disabled from January 1991 through December of 1991. In December of 1991, plaintiff was able to return to work and asserts that he was able to function normally for the next year and one-half. However, in August of 1993, plaintiff required further surgery to remove an infected epididymis, and following that surgery, he developed many symptoms, including claims of chronic low grade fevers, right groin pain, low back pain radiating down both legs, numbness of the right hand and arm with weakness of the grip, a tendency to fall a lot, fatigue and the need to sleep at least fourteen hours a day, poor eyesight, poor memory, constant headaches, digestive gas, the need to get up at least five time a night to urinate, high blood pressure, dizziness, hay fever, sinus congestion, tinnitus, and depression.¹ As a result, plaintiff was not able to work from July 30, 1993 through June of 1994. At that time, his employer, XL/Datacomp, restructured plaintiff's job by limiting the amount of territory for which plaintiff was responsible and reducing the numbers of work hours to 20 hours per week. Plaintiff asserts that although he attempted to work on a part-time basis, he was prevented from doing so by his pain and fatigue. As a result, he was placed on unpaid leave in September of 1994, and his employment with XL/Datacomp was terminated in January, 1995 because he was not able to perform the duties of his job.

In February of 1994, plaintiff filed a claim for disability benefits with MetLife. For purposes of his claim, plaintiff was considered to be "off work" since July 30, 1993. Accordingly, his effective date for the purposes of receiving disability benefits was established as January 27, 1994, because of a plan provision that precludes the payment of benefits during the first 180 days of disability. METLIND at 00479.

Plaintiff asserts that, although he has been examined and treated by a number of physicians, no one has been able to diagnose satisfactorily all of his medical problems. He has been diagnosed at various times with epididymitis, prostatitis, seminal vesiculitis, and a neurogenic bladder condition. Even though a diagnosis has not been confirmed, plaintiff continues to experience difficulties with persistent pain and chronic fatigue. Because treatment of pain and fatigue has not been successful, he has not worked on a full time basis since July 1993. He filed his claim for disability benefits in February of 1994 through the XL/Datacomp disability plan.

The claim was received by MetLife February 10, 1994. The medical records of plaintiff's primary care physician, Dr. Gordon Ehlers, were included in the materials submitted with his claim. In March of 1994, Shirley Darvasi, the Senior Claims examiner for MetLife responsible for handling plaintiff's claim, requested information from Dr. Ehlers, Dr. David Cox, and Dr. Robert Cox. During this period of time, MetLife obtained plaintiff's medical records and then sent the medical records to its paid medical consultant, Julian Freeman, for review on April 14, 1994.

After examining the medical records, Dr. Freeman concluded and prepared a report that plaintiff had the "functional capacity" to return to work, by report dated April 29, 1994. Freeman expressed his opinions in several letters written by him to MetLife. Plaintiff asserts that Dr. Freeman's reports did not include any determination whether plaintiff was totally disabled within the meaning of the language of the plan, i.e., whether plaintiff suffered a 50% loss of earnings capacity, and that he failed to identify the "material duties" of plaintiff's job and whether plaintiff could perform such duties.

On the basis of Dr. Freeman's determination that plaintiff had the "functional capacity" to return to work, MetLife denied plaintiff's claim for benefits by letter dated May 25, 1994. The entire text of that letter reads as follows:

Dear Mr. Lindsey:

We have completed our evaluation of your claim to determine your eligibility for Long Term Disability benefits.

The policy states:

Total Disability or Totally Disabled means that due to an Injury or Sickness, you:

1. are completely and continuously unable to perform each of the material duties or your regular job; and

2. require the regular care and attendance of a Doctor.

You will also be considered Totally Disabled when, due to an Injury or Sickness, you suffer a 50% loss of earnings capacity and require the regular care and attendance of a Doctor.

In addition, you must first satisfy an Elimination Period of 180 days of Total Disability.

You stated that your treating physicians were Drs. Robert Cox, David Cox, and Gordon Ehlers, so we requested records from these doctors.

Dr. Robert Cox stated that you were released and he never prohibited work. Dr. David Cox stated that he released you to return to work on September 9, 1993. However, Dr. Ehlers stated that your disability continued. Therefore, we sent your medical records, including the most recent letter from Dr. Ehlers, for review by an Independent Medical Consultant. These records were reviewed by three Board Certified physicians who conclude that the findings do not support disability. Although you have some problems, the Consultants' report indicates that you should be able to perform your occupation.

Based on the above, you are not eligible for Long Term Disability benefits.

We want you to understand that our decision in this matter has been based solely upon information contained in our file. As such, we are willing to answer any questions or to review any further objective medical evidence you would care to submit which may have an effect upon consideration given to this claim.

Metropolitan reserves all of its rights or defenses either expressly stated or implied.

You may request a review of the claim within 60 days of the denial date by writing directly to Group Insurance Claims Review, Metropolitan Life Insurance Company, at the address indicated in this letter. You should include the information contained in the Claim Identification shown above. When requesting this review, you should state the reason you believe the claim was improperly denied and you may submit any data, questions or comments to Metropolitan you deem appropriate.

Metropolitan will reevaluate all the data and you will be informed in a timely manner of our findings.

Should you have any questions, please call me.

METLIND at 00378-00379.

On July...