Rice v. Metro. Life Ins. Co.
| Decision Date | 31 March 2014 |
| Docket Number | Civil No. 12-83-GFVT |
| Parties | ROEANNE RICE, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant. |
| Court | U.S. District Court — Eastern District of Kentucky |
This matter is before the Court on cross-motions for judgment. The Court construes these as a motion to overturn the administrative decision that terminated Rice's long-term disability benefits and a motion to uphold that decision. [R.15; R. 17.] For the reasons set forth below, the Court will uphold the decision.
This case presents issues for the Court to consider under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001, et seq. As such, this Court exercises federal question subject matter jurisdiction. See Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 52-56 (1987). The important facts in this case are undisputed. Roeann Rice is 61 years old and previously worked as a clerk for nine years at Affiliated Computer Services, Inc. (ACS). As a clerk, Rice's principal responsibilities were as follows:
[ML 257.] On September 30, 2010, at age 59, Rice was injured in an automobile accident where "she suffered a broken right hand, lacerated webbing of the hand, subsequent Reflex Sympathetic Dystrophy Syndrome (RSD) from the hand injury, subsequent neuropathy from the broken hand (requiring carpal tunnel release surgery), torn rotator cuff of the right shoulder, and neck pain (disc bulge with stenosis)." [R. 15-1 at 2; ML 521-528.]
Through an arrangement with ACS, Metlife provides both short-term disability (STD) and long-term disability (LTD) benefits to ACS employees. Under the Metlife Plan, employees of ACS are eligible for STD benefits for a period of 90 days. At the end of the short-term period, employees may then apply for and receive LTD benefits. To receive LTD benefits, an employee must qualify under Metlife's definition of disability1:
[ML 648-649 (emphasis in original).] The first 24 months of the LTD period is referred to as the Own Occupation period, because Metlife only requires persons to be unable to earn 80% of earnings from "Your Own Occupation" from an employer in "Your Local Economy." [Id.] Own Occupation "means the essential functions You regularly perform that provide Your primary source of earned income." [ML 650.] Local Economy "means the geographic area: within which You reside; and which offers suitable employment opportunities within a reasonable travel distance." [ML 650.] The Summary Plan Description (SPD) elaborates on this, explaining that [ML 835.]
At the expiration of the initial 24-month, Own Occupation period, an employee enters a new temporal category (referred to as the Any Occupation period) and is judged by a more stringent disability standard. [ML 648-649.] During the Any Occupation period, applicants are only considered disabled under the Metlife policy if they are determined disabled by the Federal Social Security Act. [Id.] The Social Security Administration (SSA) defines "disability" as a:
physical or mental impairment or impairments…of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him or whether he would be hired if he applied for work.
42 U.S.C. §423(d)(2)(A).
On October 1, 2010, Rice began receiving STD benefits from Metlife, which she received for the maximum period of 90 days. [R. 15 at 2.] Subsequently, Metlife informed Rice of their determination that she was "totally disabled," could not perform her Own Occupation and was approved for LTD benefits, beginning on December 30, 2010. [ML 507.] MetLife also informed Rice of her responsibility to seek Social Security Disability Benefits (SSDI) [ML 507591; ML 661-662] and, subsequently, asked her (1) to provide proof she applied for SSDI; (2) to sign an authorization permitting Metlife access to her SSDI claim file; and (3) to sign an agreement acknowledging Rice's responsibility to refund anything she received from SSA to Metlife. [ML 507-509.] Rice submitted the required paperwork to Metlife [ML 491] and continued to receive benefits under the plan until January 31, 2011 when, upon the advice of Dr. Patrice Béliveau, she returned to work. [ML 464-465.] After briefly returning to work, Rice determined that the pain was too great and she ceased working on March 4. [ML 457-458.] Upon learning of Rice's difficulties at work, Metlife resumed paying her LTD benefits, effective March 11, 2011. [ML 434.] On May 18, Metlife sent Rice a letter inquiring about the status of her SSDI claim. [ML 413.] Rice responded, by counsel, with a letter assuring Metlife that Rice was pursuing SSDI. [ML 412.] Metlife continued to pay Rice LTD benefits until August 2, when Metlife determined that Rice was no longer disabled pursuant to the Metlife policy. [ML 360-361; R. 15-1 at 2, 5.] In a letter dated August 18, MetLife advised Rice that her LTD benefits were terminated as of August 3. [ML 360-361.] The letter explained that on July 11, 2011, Metlife had requested attending physician statements and copies of office notes and test results to confirm her continuing disability. [Id.] They considered the information they had received and concluded that there was "no clinical medical evidence to support a continuingcovered disability." [Id.]
On August 19, Rice appealed the decision and provided additional medical information from Dr. Acob to support her claim. [ML 347-351.] On September 1, Rice informed Metlife that she had been approved by the SSA for disability benefits. [R. 15-1 at 9.] Metlife responded by letter, informing Rice that her appeal request was being reviewed. [ML 344.] After conducting their internal review of the medical evidence and consulting with an independent physician consultant and a vocational expert, on November 11, Metlife affirmed its decision to terminate Rice's LTD benefits. [ML 228-232.]
"[C]ourts review such challenges to benefit determinations under the de novo standard, unless the benefit plan gives the plan administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan." University Hospital of Cleveland v. Emerson Electric, 202 F.3d 839, 845 (6th Cir. 2000) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). Rice argues that Metlife's administrative decision deserves no deference and the de novo standard applies. Metlife argues that the most deferential, arbitrary and capricious standard is to be applied. The question turns on whether the benefit plan gives Metlife discretionary authority to determine eligibility and construe the plan. University Hospital of Cleveland, 202 F.3d at 845. This question is very much in dispute and to address it, the Court must first determine what documents are part of the benefit plan.
An employee benefit plan ("the Plan") must be "established and maintained pursuant to awritten instrument." 29 U.S.C.A. § 1102. Such a plan can be designed to place ultimate liability for paying a claim on either the employer or an insurer that contracts with the employer. In this case, ACS had entered into an insurance contract with Metlife, referred to as the "Group Policy." [R. 15-1 at 13.] Under this Group Policy, ACS agrees to pay premiums to Metlife in exchange for Metlife providing insurance to ACS employees. ACS employees are then given a Certificate of Insurance ("Certificate") that explains their benefits under the Group Policy. [R. 15-1; ML 627-673.] The Group Policy and Certificate can be distinct documents; however, in this case they were one and the same (referred to as the "Certificate"). [R. 15-1 at 14; R. 20 at 13.] Employees were also given a Summary Plan Description ("SPD") that summarizes, in plain language, the employee's rights under the Plan. [R. 15-1 at 14; ML 685-938.] Also relevant in this case are two additional sections at the end of the Certificate, titled "special services" [ML 674-678] and "ERISA information" [ML 679-684].
Rice argues the de novo standard of review applies because there is no discretionary authority language in any of the Plan documents. [R. 15-1 at 13.] This argument, however, depends on a narrow interpretation of what qualifies as a...
To continue reading
Request your trial