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Bradford v. Metropolitan Life Insurance Co.

March 29, 2007


The opinion of the court was delivered by: Thomas A. Varlan United States District Judge



Plaintiff Susan Bradford filed this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., to recover long-term disability benefits from Metropolitan Life Insurance Company ("MetLife"). The case is before the Court on the plaintiff's Motion for Judgment on the Pleadings [Doc. 33] and the defendant's Motion for Judgment on the Pleadings [Doc. 38]. The plaintiff urges the Court to find that defendant erred in denying her long term disability ("LTD") benefits and to reverse the defendant's administrative decision to that effect. The defendant argues that its decision to deny plaintiff LTD benefits is supported by the administrative record and should be affirmed. The Court has carefully considered the parties' briefs [Docs. 34, 39, 41, 42, 43, 44] and the entire Administrative Record.*fn1

For the reasons set forth herein, the Court will grant plaintiff's motion for judgment on the pleadings and deny defendant's motion for judgment on the pleadings.

I. Relevant Facts

A. Claim History

Plaintiff Susan Bradford ("Plaintiff") was previously employed as a Senior Auditor for Bechtel Jacobs LLC ("Bechtel"). Plaintiff was eligible for benefits under Bechtel's Long Term Disability Plan (hereinafter the "Plan").*fn2 The Plan is funded through a MetLife insurance policy, and MetLife also administers the Plan.

The Plan provides LTD benefits for a period of disability "due to sickness, pregnancy, or accidental injury." (SPD at 0009). In order to be considered disabled under the Plan, a claimant must show that she is "receiving Appropriate Care and Treatment from a Doctor on a continuing basis" for a sickness, pregnancy, or accidental injury and:

1. During the first 24 months, including your Elimination Period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own Occupation for any employer in your Local Economy; or

2. After the first 24 month period, you are unable to earn more than 60% of your Indexed Predisability Earnings from any employer in your Local Economy at any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Predisability Earnings. Your loss of earnings must be a direct result of your sickness, pregnancy or accidental injury. Economic factors such as, but not limited to, recession, job obsolescence, paycuts and job-sharing will not be considered in determining whether you meet the loss of earnings test. (Id.). Appropriate Care and Treatment is defined as "medical care and treatment that meet all of the following:"

1. it is received from a Doctor whose medical training and clinical experience are suitable for treating your Disability;

2. it is necessary to meet your basic health needs and is of demonstrable medical value;

3. it is consistent in type, frequency, and duration of treatment with relevant guidelines of national medical, research and health care coverage organizations and governmental agencies. (Id.). The Plan also requires a claimant to "provide documented proof of [the claimant's] disability." (SPD at 0019). The Plan indicates that "[p]roof includes, but is not limited to: the date [the claimant's] Disability started; the cause of [the claimant's] Disability; and the prognosis of [the claimant's] Disability. (Id.)

Plaintiff ceased work on August 19, 2002, and filed an application for short term disability benefits.*fn3 (AR at 0256-57). Plaintiff was granted the maximum period of short term disability benefits, payable from August 20, 2002 through February 22, 2003. (AR at 0001-0005). On December 15, 2002, Plaintiff applied for LTD benefits, alleging disability because of "chronic pain, confusion, lack of short term memory, inability to follow directions, [and] falling asleep without warning." (AR at 0256). In connection with Plaintiff's application for LTD benefits, one of Plaintiff's treating physicians, Dr. Antonio Ramos, submitted an Attending Physician Statement diagnosing Plaintiff with fibromyalgia, chronic back pain, and severe depression. (AR at 0236-40). Dr. Ramos opined that Plaintiff could only work a total of two hours per day and would be unable to return to work indefinitely because of the sedating effect of Plaintiff's medications and because of her physical ailments. (Id.).

On February 10, 2003, MetLife issued its first denial of Plaintiff's application for LTD benefits. In explaining the rationale behind the denial, MetLife indicated that "we have determined that there is insufficient objective evidence documented to support the existence of a totally disabling condition preventing you from performing your own occupation. . . . For further review we would need objective documentation such as diagnostic testing such as MRI, X-rays and/or EMG." (AR at 0130-31).

In response to the denial, Plaintiff retained counsel and submitted additional information, but was again denied on April 9, 2003, because of lack of objective evidence of disability. (AR at 0121-23). In support of its second denial, MetLife relied on the opinion of Dr. Tracey Schmidt, an independent physician consultant, board certified in internal medicine and rheumatology, who was hired to perform a review of Plaintiff's file. (AR at 0125-28). Dr. Schmidt opined that the "[f]ile lacks objective evidence of a physical functional capacity impairment to a full time sedentary position with ability to stretch and change positions." (AR at 0127). With regard to Plaintiff's mental ailments, Dr. Schmidt indicated that "[f]ile mentions several mental nervous diagnoses, along with stress due to poor health of husband but I am not qualified to comment on this." (AR at 0127-28). Dr. Schmidt further opined that the "mainstream treatment for fibromyalgia is low dose antidepressants and exercise. Narcotics are not considered mainstream treatment for fibromyalgia. . . . The literature has shown that fibromyalgia patients do better if they continue to work and exercise." (AR at 0128).

On October 26, 2003, Plaintiff appealed MetLife's denial of LTD benefits and submitted additional information concerning her claim. (AR at 0200-01). On November 24, 2003, MetLife issued its third denial of LTD benefits, again finding that "there is insufficient information to support an impairment." (AR at 0112-15). The November denial relied on the opinion of Dr. Robert C. Porter, an independent physician consultant, board certified in occupational medicine, who was hired to perform a review of Plaintiff's file. (AR at 0117-19). In his report, Dr. Porter opined that the evidence contained in Plaintiff's file does not support a condition that would remove the ability of [Plaintiff] from performing sedentary work activities beyond 2/10/03. She has pain complaints that are out of proportion to her pathology and she does not appear to even qualify for the diagnosis of fibromyalgia. If she does qualify for the diagnosis of fibromyalgia, the condition does not appear to be of an extent that would remove the ability to perform sedentary to light work activities. It is well known that individuals with fibromyalgia routinely perform sedentary to light work duties that are not highly repetitive assembly line type work in nature. (AR at 0118). In response to Plaintiff's complaints of drowsiness and cognitive dysfunction, Dr. Porter opined that "[Plaintiff] does not have a condition that would benefit from ongoing narcotic medications. The medication should be reduced and if there is cognitive dysfunction, this would be remedied by the reduction in narcotic medications." (Id.). Dr. Porter did not address Plaintiff's diagnosis of depression. (AR at 0117-19). Additionally, the November denial indicated that Plaintiff had exhausted her administrative remedies and that no further appeals would be considered. (AR at 0115).

In response to the November denial, Plaintiff retained new counsel and submitted additional information concerning her claim. (AR at 0013-11, 0132-60). In response, MetLife issued a letter, dated November 4, 2004, stating that the November 24, 2003, decision was the final decision on review and that the additional information submitted "does not change our decision." (AR at 0012). In response, Plaintiff filed the instant action. [Doc. 1].

B. Plaintiff's Relevant Medical History

1. Dr. Antonio Ramos

Dr. Antonio Ramos, Plaintiff's internal medicine doctor, submitted a number of medical records covering his treatment of the ailments supporting Plaintiff's disability claim. On May 24, 2002, Dr. Ramos saw Plaintiff for chronic back and neck pain, as well as allergic rhinitis. (AR at 0299). Dr. Ramos also indicated that Plaintiff was not sleeping well at night, was suffering from hypersomnia during the day, and was taking several different pain medications, which might be causing some sedation. (Id.). Plaintiff was diagnosed with chronic back and neck pain, HTN, and allergic rhinitis. (Id.). Dr. Ramos prescribed water physical therapy and a reduction in pain medication. (Id.).

On August 16, 2002, Dr. Ramos again saw Plaintiff concerning her chronic pain. (AR at 0294). Dr. Ramos's physical examination found "[d]ifferent tender spots throughout the back, upper and lower, hips, knees, shoulders," and he diagnosed Plaintiff with chronic myalgias, athralgias, deteriorating weakness of back and leg muscles, severe depression, and possible fibromyalgia. (Id.). Plaintiff was referred to Dr. Sizemore and Dr. Burns for rheumatologic evaluation. (Id.).

On September 12, 2002, Dr. Ramos saw Plaintiff for her continuing back pain. (AR at 0292). Dr. Ramos's exam indicated that Plaintiff had multiple tender spots throughout the joints and back with decreased range of motion. (Id.). Dr. Ramos noted that Plaintiff had scheduled appointments ...

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