Sigai v. Metro. Life Ins. Co.

• Decision Date: 18 August 2014
• Docket Number: Case No. 11-1130-DDC-KGG
• Parties: ANDREW GARY SIGAI, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, as Administrator of the Philips Electronics North America Long-Term Disability Program, Defendant.
• Court: U.S. District Court — District of Kansas

ANDREW GARY SIGAI, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY,as Administrator of the Philips Electronics North America Long-Term Disability Program, Defendant.

Case No. 11-1130-DDC-KGG

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS

August 18, 2014

MEMORANDUM AND ORDER

Plaintiff brings this action under 29 U.S.C. § 1132(a)(1)(B) of the Employment Retirement Income Security Act of 1974 ("ERISA") to recover unpaid benefits allegedly due to him under the terms of a long-term disability plan (the "Plan") issued by defendant. Plaintiff also seeks declaratory relief requesting that the Court enjoin defendant's actions that violate the Plan and enforce the Plan under 29 U.S.C. § 1132(a)(3). Additionally, plaintiff requests attorney's fees and costs under 29 U.S.C. § 1132(g)(1).

This matter is before the Court on defendant's Motion for Summary Judgment (Doc. 59) and plaintiff's Motion for Judgment on the Administrative Record (Doc. 61). As set forth below, based upon a review of the evidence in the administrative record, the Court finds that plaintiff has not established that he met the definition of "disability" under the Plan before he retired from his employment on May 1, 2007, and his coverage under the Plan terminated. Therefore, the Court rules that plaintiff is not entitled to benefits under the Plan and accordingly grantsdefendant's Motion for Summary Judgment (Doc. 59). Likewise, the Court denies plaintiff's Motion for Judgment on the Administrative Record (Doc. 61).

I. FACTUAL BACKGROUND

The following facts are uncontroverted. Plaintiff was employed by Philips Electronics North America Corporation ("Philips") as a Fellow Engineer.¹ The last day that plaintiff worked for Philips was April 30, 2007.² His employment with Philips terminated effective May 1, 2007, due to retirement.³ Plaintiff was 62 years old at the time of his retirement.⁴

The Plan

While employed, plaintiff participated in the Philips Electronics North America Corporation Signature Long Term Disability Plan (also known as the Philips Electronics North America Corporation Long-Term Disability Program) (the "Plan") which is governed by ERISA, 29 U.S.C. §§ 1001, et seq. At the time of plaintiff's retirement and through 2008, the Plan was funded by a group policy of long term disability ("LTD") insurance issued by defendant to Philips.⁵ Defendant served as the claims administrator for the Plan and was responsible for claims' determinations and for determining appeals from denials of claims.⁶

The Plan's Summary Plan Description ("SPD") provides the following definition of disability:

Definition of Total Disability

On or After January 1, 2002

For those who become disabled January 1, 2002 and after, the definition of "disability" below will apply:

• For the first 2 ½ years, you will be considered disabled if you are unable to earn more than 80% of your indexed pre-disability earnings at your own occupation for any employer in your local economy.

• After 2 ½ years, you will be considered disabled if you are unable to earn more than 60% of your indexed pre-disability earnings from any employer, at any occupation for which you are reasonably qualified, taking into account your training, education, experience and pre-disability earnings.

. . .

In all cases, "Disability" means that due to sickness, pregnancy or accidental injury, you are receiving appropriate care and treatment from a medical doctor on a continuing basis.⁷

The SPD also provides:

When LTD Coverage Ends

Your long-term disability coverage ends on the earliest of the following dates, provided that you are not receiving an LTD benefit:

• When you are no longer an eligible employee (e.g., you become a part-time employee working less than twenty hours per week)

• When the program is terminated

• When you retire

• When you go on strike or are locked out

• When your employment terminates

If you are on an unpaid lay off or an unpaid leave of absence, your coverage stops on your last day of work.⁸

The Plan's certificate of insurance also defines "Disability" and describes the circumstances under which coverage ends.⁹ The certificate of insurance also provides:

Proof of Disability

Provide proof of Disability within 3 months after the end of your Elimination Period.

No benefits are payable for claims submitted more than one year after the date of Disability. However, you can request that benefits be paid for late claims if you can show that:

1. it was not reasonably possible to give written proof of Disability during the one year period; and

2. proof of Disability satisfactory to us was given to us as soon as was reasonably possible.

. . .

Legal Actions

No legal action of any kind may be filed against us:

1. within the 60 days after proof of Disability has been given; or

2. more than three years after proof of Disability must be filed. This will not apply if the law in the area where you live allows a longer period of time to file proof of Disability.¹⁰

The Plan gives discretionary authority to defendant by providing:

Discretionary Authority of Plan Administrator and Other Plan Fiduciaries

In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have 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 interpretation or determination was arbitrary and capricious.¹¹

The SPD provides the same discretionary authority to defendant:

Discretionary Authority

MetLife shall have the exclusive right, power, and authority in its sole and absolute discretion to administer, apply and interpret the plan and any other plan documents, and to determine eligibility for and entitlement to plan benefits and todecide all matters arising in connection with the operation or administration of the plan.¹²

Plaintiff's Social Security Claim and Award

After retiring from Philips in May 2007, plaintiff moved from Kansas to New Hampshire.¹³ In New Hampshire, plaintiff sought treatment from a cardiologist, Mary-Claire Paicopolis, M.D.¹⁴ After plaintiff had an abnormal stress test, Dr. Paicopolis referred him to Beth Israel Deaconess Medical Center for a cardiac catheterization, which occurred on January 31, 2008.¹⁵ On September 8, 2008, Dr. Paicopolis asked plaintiff to apply for Social Security disability.¹⁶

Plaintiff's Social Security disability claim was initially denied,¹⁷ but in a February 26, 2010, decision, an Administrative Law Judge ("ALJ") awarded plaintiff Social Security disability benefits.¹⁸ In that decision, the ALJ determined that plaintiff had been disabled under sections 216(i) and 223(d) of the Social Security Act since May 1, 2007.¹⁹

Plaintiff's Claim to Sedgwick Claims Management Services, Inc.

Plaintiff first submitted a claim to Sedgwick Claims Management Services, Inc. ("Sedgwick"), the claims administrator for Philips Salary Continuance benefits, on May 20,2010.²⁰ Sedgwick denied plaintiff's claim in letters dated May 21, 2010, and August 18, 2010.²¹ In the August 18, 2010 letter, Sedgwick described the claim as a one for short term disability ("STD") benefits.²² Sedgwick further stated that it was denying the claim because plaintiff's accident and sickness insurance terminated on his last day of work, April 30, 2007, and his first day of disability was May 1, 2007.²³ Plaintiff appealed the denial,²⁴ and Sedgwick upheld the denial by letter dated January 17, 2011.²⁵

Plaintiff's LTD Claim to Defendant

Plaintiff submitted his LTD claim to defendant in a letter dated March 7, 2012.²⁶ In that letter, plaintiff explained that he "was dealing with multiple medical issues prior to his leaving Philips' employment, including diabetes, hypertension, sleep apnea, restrictive lung disease, coronary artery disease, and hypercholesterolemia."²⁷ Plaintiff submitted the following documents with his LTD claim: the fully favorable decision of the Social Security Administration and accompanying notification,²⁸ portions of his application for Social Securitydisability benefits,²⁹ some medical records,³⁰ Dr. Paicopolis' Medical Source Statement (that was submitted to the Social Security Administration),³¹ and MetLife's Personal Profile forms.³² In the Personal Profile form, plaintiff listed his physicians and their specialties: Mary-Claire Paicopolis, M.D., Gilford, NH, Cardiology; Roger J. Laham, Beth Israel Deaconess Medical Center, Boston, MA, Interventional Cardiology; Paula Goodman Fraenkel, Beth Israel Deaconess Medical Center, Boston, MA, Hematology / Oncology; Susan Herzlinger Botein, Joslin Clinic, Boston, MA, Endocrinology, Diabetes & Metabolism; David Roberts, Beth Israel Deaconess Medical Center, Boston, MA, Pulmonary, Critical Care & Sleep Medicine; Jacqueline Chang, Beth Israel Deaconess Medical Center, Boston, MA, Pulmonary, Critical Care & Sleep Medicine; Mark Slovenkai, Boston Sports & Shoulder Center, Waltham, MA, Orthopedic Surgery (foot); Paul Weitzel, Boston Sports & Shoulder Center, Waltham, MA, Orthopedic Surgery (shoulder); Anthony Aversa, Dermatology Associates, Concord, NH, Dermatology; Kirsten Helling, Coppola Physical Therapy, Tilton, NH, Physical Therapy; Salina Clinic, L.L.C., Salina, KS.³³

On April 26, 2012, defendant interviewed plaintiff by telephone.³⁴ Defendant also received medical records from plaintiff's listed physicians, some of which are described in more detail below.

Records from Dr. Hanson of the Salina Clinic

On July 6, 2005, plaintiff visited Dr. Hanson, who noted plaintiff's history of a myocardial infarction in 1994 and plaintiff's "insulin dependent diabetes mellitus since 1988, controlled with diet and meds, hypertension, hypercholesterolemia."³⁵ On September 2, 2005, Dr. Hanson recommended that plaintiff see Wini Schaedel, ARNP, Certified Diabetes Educator.³⁶ Plaintiff...