Solomon v. Metropolitan Life Ins. Co.
| Decision Date | 18 June 2009 |
| Docket Number | No. 06 Civ. 2375.,06 Civ. 2375. |
| Citation | 628 F.Supp.2d 519 |
| Parties | Tracy SOLOMON, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY and Oxford Health Insurance Co., Defendants. |
| Court | U.S. District Court — Southern District of New York |
Koob & Magoolaghan, by Elizabeth L. Koob, Esq., Yonkers NY, for Plaintiff.
LESTER SCHWAB KATZ & DWYER, LLP, by Allan M. Marcus, Esq., New York, NY, for Defendants.
Defendants Metropolitan Life Insurance Company ("MetLife") and Oxford Health Plans, Inc. ("Oxford") (collectively, the "Defendants") have moved under Rule 56, Fed.R.Civ.P., for summary judgment dismissing the complaint of plaintiff Tracy Solomon ("Solomon" or the "Plaintiff") and granting their cross counterclaim seeking recovery of benefits paid. Solomon has cross-moved under the same rule for summary judgment granting her the relief she has sought under the Oxford Employee Welfare Plan (the "Plan") and dismissing Defendants' counterclaim. Upon the findings and conclusions set forth below, Defendants' motion is denied, and the cross motion of Solomon for summary judgment on her claim is granted.
Solomon filed her complaint on March 27, 2006, seeking to compel MetLife to grant her benefits under the Plan.
Defendants filed their motion for summary judgment on March 18, 2008. Plaintiff's cross motion was filed on July 14, 2008. The motion and cross motion were marked fully submitted on August 20, 2008.
The facts have been set forth in the Defendants' Local Rule 56.1 Statement, the Plaintiffs Response, the Plaintiff's Local Rule 56.1 Statement, and the Defendants' Response and are not in dispute except as noted below.
Oxford established and maintains an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. The Plan provides long-term disability ("LTD") benefits to eligible employees.
MetLife is the Plan's claims administrator and also funds Plan benefits through a group policy of insurance. As Plan administrator, MetLife has "discretionary authority to interpret the Plan and determine eligibility and entitlement to Plan benefits in accordance with the terms of the Plan." Affidavit of Margaret A. Calderon ("Calderon Aff."), Exh. B, Summary Plan Description ("SPD") at 44.
To be eligible for LTD benefits, a participant must "require the regular care and attendance of a Doctor and [be] unable to perform each of the material duties of your regular job." Id., SPD at 21. After the first 24 months of LTD benefit payments, the definition of disability changes to mean the inability to perform the duties of "any gainful work or service for which you are reasonably qualified taking into consideration your training, education, experience and past earnings." Id.
Under the Plan, a participant-claimant must provide documented proof of disability "satisfactory to [MetLife]." Id., SPD at 33. As claims administrator, MetLife is responsible for initially reviewing claims and determining benefits eligibility. If a claim is denied, the participant may appeal to MetLife, which will render a final claim decision.
The Plan provides that monthly LTD benefits are reduced by "Other Income Benefits," including Social Security Disability Income ("SSDI") benefits. The Plan also provides that any overpayment of LTD benefits due to the retroactive receipt of Other Income Benefits shall be refunded to MetLife. If a claimant signs an agreement to repay MetLife any such overpayment, MetLife will not reduce monthly LTD benefits by an estimate of SSDI benefits.
Solomon, a registered nurse, was employed by Oxford as a medical claim case manager, which is a sedentary job. Solomon worked at Oxford until March 16, 1999, when she claimed to be disabled due to back pain following a fall.
Effective September 8, 1999, MetLife approved Plaintiff's LTD benefits claim. MetLife received medical information from Solomon's treating orthopedic surgeon, Dr. L. Starace ("Dr. Starace"), who diagnosed Solomon with lumbar radiculopathy and fibromyalgia, and from her treating rheumatologist, Dr. H. Paul Laskey ("Dr. Laskey"), and physical therapist, Gene Pavone ("Pavone").
Solomon signed an agreement to repay MetLife any overpayment of LTD benefits generated by receipt of SSDI benefits. MetLife assigned a Social Security specialist to work with Solomon to obtain SSDI benefits who reported that Solomon was a feasible candidate for SSDI benefits due to her multiple conditions.
In July 2000, MetLife also arranged for independent orthopedist Dr. Ralph Purcell ("Dr. Purcell") to examine Solomon. In an independent medical examination ("IME") report dated August 1, 2000, Dr. Purcell found no objective medical basis for any disability from an orthopedic standpoint. On the basis of the IME, MetLife terminated Solomon's benefits effective September 19, 2000, and Solomon appealed.
MetLife then had the claim file reviewed by an independent rheumatologist, Dr. J. Lieberman ("Dr. Lieberman"), who opined that Solomon's fibromyalgia was not disabling, but that more information should be obtained regarding a neurological diagnosis. Following discussion with Dr. S. Fromm ("Dr. Fromm"), Solomon's treating neurosurgeon, Dr. Lieberman stated that Solomon's neurological problems might be disabling and recommended a reassessment in three months.
By letter of January 26, 2001, MetLife notified Plaintiff that her LTD benefits were being reinstated.
Solomon then submitted a "Personal Profile" form to MetLife dated October 11, 2002, along with a handwritten addendum in which she set forth numerous restrictions on her daily living activities and general limitations "for varying amounts of time due to stiffness, pain and dizziness." Affidavit of Margaret A. Calderon ("Calderon Affidavit"), Exh. A, Claim File at 498-99. With respect to driving, Solomon answered "Yes" to the question "Do you drive?" explaining that:
It is difficult to sit and focus and concentrate to drive and I also get dizzy and have the feeling of moving when not in motion. I do not drive unless it is to the convenient [store] one-quarter mile from my home. The doctors all have restricted driving.
Id., Claim File at 504. With respect to shopping, she stated, and further that, among other limitations, Id., Claim File at 499, 504.
On November 12-14, 2002, MetLife conducted surveillance of Solomon. A video and written report of the surveillance were prepared. The surveillance report notes that Solomon was able to drive to a medical appointment and to the grocery store, was able to lift and carry grocery bags, and was observed walking and bending with apparent discomfort and distress. The MetLife referral form for medical review characterizes the surveillance video in the Brief Summary of Claim as, "Compelling video from 11/2002 demonstrating EE's high level of functioning." Id., Claim File at 650.
According to Plaintiff, the surveillance video shows her engaging in no activity on November 12, 2001, and less than ten minutes of activity carrying bags of groceries from her car approximately 20 steps to her first floor apartment on November 13, 2001. The surveillance report states that on November 14, 2001, Solomon drove her car 7-9 minutes to and from a doctor's office with no further activity observed for the day. According to Solomon, a whitepage.com search for the doctors who are reported to have offices in the building to which Solomon traveled informs that the address was 3 College Rd., Monsey, New York, not Rockland, New York, as stated in the report. Mapquest estimates that the drive from Solomon's home to the doctors' building takes 5 minutes to travel the 2.22 mile distance. This estimate is disputed by MetLife.
According to Solomon, there is no documentation in the diary notes or elsewhere in the claim file indicating that any claims administrator, reviewer, or medical consultant actually viewed or even requested to view the surveillance video. MetLife took no action against Solomon based upon the November 2002 surveillance until more than a year later when it referenced the report in the referral of the file to Dr. Amy Hopkins ("Dr. Hopkins") on January 8, 2004.
In July 2003, MetLife received a Notice of Disapproved Claim dated January 27, 2003, from the Social Security Administration ("SSA"). The SSA denied Solomon's claim for SSDI benefits, stating that it had "determined that [Solomon's] condition is not severe enough to keep [her] from working." Id., Claim File at 447. Solomon's attorney notified MetLife of her request for a hearing on the denial.
On August 27, September 25, and November 25, 2003, MetLife requested updated medical records from Solomon. During the period from her application for LTD benefits on March 10, 1999, to the December 1, 2003 termination of benefits, MetLife requested updated medical information from Solomon or her doctors on 34 separate occasions.
By letter dated November 25, 2003, MetLife notified Solomon that, as no recent documentation had been submitted to support her disability claim, benefits would be terminated effective December 1, 2003. In December 2003 and January 2004, MetLife received various medical records from Solomon and her treating physicians. Among these were:
(i) Office notes of Dr. Fichman, a rheumatologist, describing the treatment for Solomon's fibromyalgia. Dr Fichman also described Solomon as "[n]eurologically ... grossly intact."
(ii) A March 20, 2003 report from Dr. Fromm describing his examination of Solomon. Dr. Fromm's diagnosis was peripheral polyneuropathy, with symptoms of decreased sensation in...
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