Zhou v. Metro. Life Ins. Co.

• Decision Date: 02 September 2011
• Docket Number: Civil Action No. 09–CV–01516–AW.
• Citation: 807 F.Supp.2d 458
• Parties: David ZHOU a/k/a Zongde Zhou, Plaintiff, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — District of Massachusetts

807 F.Supp.2d 458

David ZHOU a/k/a Zongde Zhou, Plaintiff,

v.METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

Civil Action No. 09–CV–01516–AW.

United States District Court, D. Maryland, Southern Division.

Sept. 2, 2011.

Jonathan R. Bromberg, Scott Adam Mirsky, Bromberg Rosenthal LLP, Rockville, MD, for Plaintiff.

David A. Carter, Meyers Rodbell and Rosenbaum PA, Baltimore, MD, for Defendant.

MEMORANDUM OPINION

ALEXANDER WILLIAMS, JR., District Judge.

This case arises from the denial of coverage for long-term disability benefits after Plaintiff David Zhou, an employee of American Computer Technology, Inc. (hereinafter “ACT”), was diagnosed with a depressive disorder and filed an insurance disability claim. Pending before the Court is Defendant Metropolitan Life Insurance Company (hereinafter “MetLife”)'s motion for summary judgment, Doc. No. 33, and Plaintiff David Zhou's cross-motion for summary judgment, Doc. No. 36. For the reasons that follow, the Court DENIES the parties' cross-motions for summary judgment and REMANDS Plaintiff's claim to the plan administrator for a full and fair review consistent with this Memorandum Opinion.

I. STATEMENT OF FACTSA. Plaintiff's Employment And MetLife's Disability Plan

On August 25, 2005, ACT hired Plaintiff as a Senior Consultant. Administrative Record (hereinafter “AR”) at 585. According to Plaintiff's job description, Plaintiff worked forty hours a week plus overtime, totaling sixty to sixty-five hours a week. AR at 489. His job required the ability to concentrate and think clearly to formulate and define software systems, manage projects, and create objectives for projects. Id. Specifically, Plaintiff's job duties required excellent memory skills, mental clarity, and the ability to manage deadlines and projects, create project details, analyze several components at one time, and problem solve. Id.

Plaintiff, through a group policy provided by ACT, was a participant in MetLife's Long–Term Disability Insurance Plan (hereinafter “Plan” or “Benefits Plan”). MetLife funds long-term disability insurance as provided under the Plan and also serves as the Claims Administrator. Plaintiff's coverage under the Plan became effective on September 1, 2005. AR at 646. The Plan provides in pertinent part:

LONG TERM DISABILITY BENEFITS (AR at 678)

A. Monthly Benefit

You will be paid a Monthly Benefit, in accord with Plan Highlights, if we determine that:

1. You are Disabled; and

2. You became Disabled while covered under The Plan.¹

BENEFITS CHECKLIST (AR at 677)

In order to receive benefits under This Plan you must provide to us at your expense, and subject to our satisfaction, all of the following documents ...

1. Proof of Disability

2. Evidence of continuing Disability

3. Proof that you are under the Appropriate Care and Treatment of a Doctor throughout your Disability

4. Information about other income benefits

5. Any other Material information related to your Disability which may be requested by us.

* * * * * *

DEFINITION OF DISABILITY (AR at 680)

“Disabled” or “Disability” means that, due to sickness, pregnancy, or injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis; and you are unable to earn more than 80% of your Pre-disability Earnings or Indexed Pre-disability Earnings at your Own Occupation for any employer in your Local Economy....”

* * * * * *

LIMITATION FOR DISABILITIES DUE TO PARTICULAR CONDITIONS (AR at 688)

Monthly benefits are limited to 24 months during your lifetime if you are Disabled due to a:

I. Mental or Nervous Disorder or Disease, unless the Disability results from:

a. schizophrenia;

b. bipolar disorder;

c. dementia;

d. organic brain disease.

“Mental or Nervous Disorder or Disease” means a medical condition of sufficient severity to meet the diagnostic criteria established in the current Diagnostic and Statistical Manual of Mental Disorders. You must be receiving Appropriate Care and Treatment for your condition by a mental health Doctor.

* * * * * *

DOCUMENTATION OF CLAIMS (AR at 692–93)

At your expense, you must provide documented proof of your Disability. Proof includes, but is not limited to:

1. the date your Disability started;

2. the cause of your Disability;

3. the prognosis of your Disability

You will be required to provide signed authorization to obtain and release medical and financial information, and any other items we may reasonably require in support of your Disability. These will include, but are not limited to:

1. Proof of continuing Disability ...

* * * * * *

B. Events Leading Up to Plaintiff's Disability

In December 2005, Plaintiff's mother died from undiagnosed cancer. AR at 424. On December 23, 2005, Plaintiff took two weeks leave of absence to attend the funeral in China. Plaintiff alleges he planned to return after the two weeks but became depressed in China and was too sick to leave. AR at 717. Plaintiff remained in China and began seeing Dr. Wang Wei, who diagnosed Plaintiff with depressive disorder and proscribed Prozac, Valium, and Nimodipine for treatment. AR at 491–93. Plaintiff remained in treatment under the care of Dr. Wei until March 30, 2006, when he returned to the United States. Id.

On May 22, 2006, Plaintiff sought treatment for his depression in the United States with Dr. David Grodsky, M.D., of Threshold Services Outpatient Mental Health Center (hereinafter “Threshold Services”). AR at 664–66. Threshold Services is a reduced-fee clinic for adults with mental disorders. At that time, Plaintiff also began seeing Bonnie Jones, a Licensed Certified Social Worker–Clinician for Threshold Services. AR at 629–35. Over the two-year course of his treatment at Threshold Services, Plaintiff suffered a number of symptoms, including depressed moods, dizziness, decreased energy, poor concentration and memory, lack of motivation, isolation, panic attacks, and high anxiety.² In sum, Plaintiff had regular weekly, monthly and sometime bi-monthly appointments with Threshold Services, and his doctors prescribed a number of medications including Klonopin, Seroquin, Lexapro, and Cymbalta to help with Plaintiff's depression and other related symptoms. Plaintiff saw Dr. Grodsky until June 13, 2006. AR at 713. Dr. Andres Olaciregui, M.D., took over in June 2006 and became Plaintiff's treating physician. Id. Plaintiff subsequently received treatment from Drs. Brian Zimnitzky and Abby Morris from around April 10, 2007 to January 22, 2008. AR at 99–112. On September 26, 2008, Dr. Morris diagnosed Plaintiff with Bipolar Attentive Disorder, General Anxiety Disorder and paranoia. AR at 26.

MetLife became aware of these medical records and diagnoses supporting Plaintiff's condition in a piece-meal fashion during its four reviews of Plaintiff's claim for disability benefits. Because the Court is limited to determining whether MetLife's denials were reasonable based on the information available to MetLife at the time, the Court will proceed to discuss in depth the information available to MetLife at each juncture in which it denied Plaintiff's claims for long-term benefits.

C. MetLife's Initial Review of Plaintiff's Claim

On April 2, 2006, Plaintiff faxed a long-term disability employee statement form and an Attending Physician Statement (“APS”) to MetLife. AR at 668–70. The APS submitted was that of Dr. Wei, who had treated Plaintiff in China. Id. The APS stated that Plaintiff had depressive disorder with symptoms including headaches, dizziness, depression, poor concentration and poor memory due to headaches, dizziness and insomnia. Id. Dr. Wei stated that “it would take one to two years to cure this kind of illness” and referenced SAS, SDS and SCL–90 charts, although these charts were not provided. Id. Plaintiff also submitted an APS from Dr. Grodsky at Threshold Services. The APS stated that Dr. Grodsky diagnosed Plaintiff with major depression and indicated that Plaintiff had “too little concentration currently” to return to work. AR at 665.

On July 17, 2006, Plaintiff faxed an employer statement to MetLife at MetLife's request. AR at 711. The employer statement contained a brief job description in which Plaintiff's employer indicated that Plaintiff's position entailed working forty hours per week plus overtime. AR at 654. The statement indicated that overtime was regularly required and that the job requires moving equipment and/or other machinery from time to time. Id. The statement also noted that frequently, up to 88% of the time, is Plaintiff required to encounter interpersonal relationships necessary to perform the job. Id.

On July 18, 2006, Plaintiff called MetLife to confirm that it received the employer statement and to inquire if there was any additional information that MetLife needed. AR at 711. MetLife advised Plaintiff that it had received the employer statement, that nothing else was needed at this time and that once the review was complete, the case manager would advise Plaintiff if MetLife needed anything else. Id.

On August 3, 2006, after two previous attempts to get in contact with Plaintiff, MetLife faxed a request to Dr. Olaciregui's office and asked that he return an enclosed questionnaire that MetLife needed in order to assess Plaintiff's disability. AR at 713. MetLife specifically required information such as initial and ongoing documentation of Plaintiff's current psychological condition, a current diagnosis, a GAF score,³ treatment plan, medication regiment, current clinical symptoms, return-to-work plan, estimated return-to-work date, and any specific cognitive and functional impairments that would support Plaintiff's inability to return to work. Id. MetLife requested that Dr. Olaciregui return the form by August 17, 2006. Id.

On August 4, 2006, Plaintiff called MetLife and informed MetLife that he could not retrieve any more information from Dr. Wei because China did not have a policy of keeping medical records of outpatients. AR at 608. On August 7, 2006, MetLife...