United States District Court, D. Oregon, Eugene Division
JANE A. MEDEFESSER, Plaintiff,
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.
FINDINGS AND RECOMMENDATION
MUSTAFA T. KASUBHAI UNITED STATES MAGISTRATE JUDGE
a participant in short-term and long-term disability plans
brought an Employee Retirement Income Security Act
(“ERISA”) action against plan administrator
Metropolitan Life Insurance Company (“Metlife”).
The parties filed cross motions for judgment pursuant to Fed.
R. Civ. Pro. 52(a) and the Court heard oral argument.
reasons discussed below, the Court should reverse
Metlife's decision and remand this case for the
reinstatement and payment of benefits as long as Plaintiff
remains disabled under the terms and conditions of the
long-term disability plan.
suffers from multiple medical conditions including
fibromyalgia, migraines, rotator cuff syndrome,
scapulohumeral bursitis, hypersomnia with sleep apnea,
Attention Deficit Disorder (“ADD”), and lumbar
sprain/strain. AR 332. Her symptoms were diagnosed between
2010 and 2012 by her primary physician Dr. Supplitt. AR 331,
333, 1641, 1644. Plaintiff's treating rheumatologist Dr.
Karplus diagnosed her with wrist pain and Sicca syndrome in
March 2013. AR 360. Plaintiff also reported “brain
fog” and focus and communication problems. AR 412. In
August 2014, psychologist Dr. Pugh performed cognitive
testing on Plaintiff. AR 255-60. Dr. Pugh opined that
Plaintiff's intelligence and cognitive abilities fell
into the average range but noted that Plaintiff “is
experiencing an increase in mental health, cognitive and
physical symptoms that are impacting her ability to function
as she did previously.” AR 256.
left employment effective March 10, 2014. AR 406. She applied
for Short Term Disability (“STD”) benefits in
March 2014. AR 312-16. Metlife denied her STD claim and her
subsequent appeal. AR 300-02, 179-84. Plaintiff then applied
for Long Term Disability (“LTD”) benefits. AR
1620-29. Metlife denied her LTD claim. AR 2320-27. Plaintiff
appealed. AR 1233-51. On appeal, Plaintiff submitted
additional medical records and information, including a
Cardiopulmonary Exercise Test (“CPET”)
administered by Christopher Snell, Ph.D., which measured
Plaintiff's capacity for physical activity. AR 1252-61
(test dates: September 23-24, 2015; report Dated: October 13,
2015). Snell concluded that Plaintiff's threshold for
“sustained limit of activity” precluded her from
sustaining sedentary, seated office work and “[e]ven a
sedentary job would require more energy than she is able to
safely sustain.” AR 1257. Plaintiff also submitted a
letter from Dr. Supplitt, who opined that the CPET results
and Dr. Pugh's testing demonstrated that Plaintiff
required significant work restrictions that rendered her
“unable to sustain full-time or part-time work of any
kind.” AR 1262-63.
requested review of Plaintiff's medical records by
neuropsychologist Dr. Kadushin and internalist and
rheumatologist Dr. Schmidt. Dr. Kadushin concluded that there
was “no clear evidence of any psychological disorder
that would result in impairment and functional
limitations.” AR 2948-49. Dr. Schmidt concluded that
“[t]he file supports clinical evidence of a physical
impairment to a full time occupation in any physical demand
category from 3/10/14 forward.” AR 1204. Dr. Schmidt
agreed with Dr. Supplitt that the pain was multifactorial,
resulting from “Sjogren's, patellofemoral disease,
fibromyalgia, myofascial dysfunction, migraines, rotator cuff
syndrome, back pain with sacroiliac dysfunction, neck pain
and wrist tendonitis.” Id. Dr. Schmidt cited
the CPET as the “objective measures that can clearly
distinguish between indolence and true disability” and
noted that the findings were consistent with Plaintiff's
“subjective complaints and objective findings on
exam.” AR 1206-07. Dr. Schmidt did not offer an opinion
on Plaintiff's cognitive condition, noting that
“the file reports cognitive issues which is not my area
of expertise and [I] would defer that to a reviewer in
psychiatry to comment on the claimant's mental
capabilities.” AR 1188. Based on her review of
Plaintiff's physical impairment, Dr. Schmidt recommended
restrictions precluding employment in all occupations. AR
February 22, 2016, Metlife approved Plaintiff's LTD
benefits under the “own occupation” standard
following Dr. Schmidt's opinion. AR 1162-64, 1172.
29, 2016, Metlife received updated medical records from Dr.
Karplus, which included a note from Plaintiff's May 23,
2016 appointment when Plaintiff reported that she was serving
as her ailing mother's primary caregiver. AR 793. Metlife
referred Plaintiff to an in- person physical examination by
Dr. Armstrong-Murphy, a physician specializing in physical
medicine and rehabilitation. AR 999-1007. Dr.
Armstrong-Murphy reviewed Plaintiff's medical records and
examined her. AR 1000-04. Dr. Armstrong-Murphy concluded that
“[a]ll sedentary activities would be reasonable
throughout an 8-hour day at a full-time capacity, ”
with limitations on bending, lifting, and overhead activity.
Id. at 1006. Metlife terminated Plaintiff's LTD
benefits effective March 9, 2017 stating that she no longer
satisfied the “any occupation” definition of
disability. AR 969. Specifically, Metlife noted that
“[Plaintiff has] the functional ability to perform full
time sedentary work” “based on the IME
[independent medical evaluation] exam and report.” AR
971. Plaintiff appealed the termination.
appeal, Plaintiff submitted treatment notes of Dr. Supplitt
and Dr. Karplus for 2016-2017, and a letter from Dr.
Supplitt. AR 793-848. Dr. Supplitt opined in the letter that
Plaintiff's conditions “make her disabled
permanently for any type of work.” AR 847. In
particular, Dr. Supplitt does not think Plaintiff
“would be able to sustain even 2 hours office work a
day.” AR 848. “Within even a 2 hour timeframe she
would likely need 3-4 breaks of 5 minute duration. In a
theoretical full-time job[, ] … she would miss work at
least 75% of the time.” Id. Dr. Supplitt also
opined that “I would agree with the assessment of the
Social Security Administration that she is totally disabled.
I do not foresee any future course of treatment will change
that.” Id. Plaintiff underwent a
neuropsychological evaluation in May 2017 by
neuropsychologist Dr. Goodwin. AR 849-66. Dr. Goodwin noted a
“clear decline from her prior level of
functioning” and in particular, “there is a clear
pattern of neurocognitive dysfunction in aspects of attention
and concentration and in some areas of processing
speed.” AR 865. Dr. Goodwin concluded:
In summary, given the nature of her prior employment with the
likelihood of very little room for error, in my opinion, it
is quite clear that she is not work tolerant from a
neuropsychological stand point. This is generally consistent
with the consensus of health care providers who are involved
in her ongoing treatment with her.
Id. Dr. Goodwin further explained that
“[a]lthough fatigue is difficult to measure, from a
qualitative standpoint, this may well be the most disabling
aspect in terms of understanding her neuropsychological
sought neuropsychologist Dr. Becker's review of
Plaintiff's records. Dr. Becker noted that Dr. Pugh's
testing was “brief and substantially more
consolidated” and “a clear pattern of heightened
symptom endorsement … was not objectively assessed by
the evaluator.” AR 694. Regarding Dr. Goodwin's
testing, Dr. Becker noted the lack of underlying testing data
and a validity test. AR 693. Dr. Becker concluded that
“there were no compelling supporting documents for a
psychiatric diagnosis that would manifest with symptoms and
limitations that would prevent the claimant from being able
[to] work at a full-time capacity.” AR 697. Metlife
also sought review by Dr. Marwah, an internal medicine and
rheumatology physician. Dr. Marwah observed Plaintiff's
“fibromyalgia with tender points, mild rotator cuff
tendinitis, and degenerative lumbar spine disc disease,
” but found that “this should not be an
impediment at all to her work performance.” AR 682. Dr.
Marwah further found that “[t]here is no objective
evidence to support this claimant's inability to work on
a full-time regular basis without any restriction or
limitation based on the documentation submitted and the
reports from the various providers.” Id.
upheld its decision to terminate benefits following its
review of Plaintiff's appeal. AR 653-60. Plaintiff filed
denial of [ERISA] benefits … must be reviewed under
de novo standard unless the benefit plan expressly
gives the plan administrator or fiduciary discretionary
authority to determine eligibility for benefits ...”
Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 109 (1989). “If the benefits plan provides the
plan administrator with ‘discretionary authority to
determine eligibility for benefits,' review is for abuse
of discretion.” Rabbat v. Standard Ins. Co.,
894 F.Supp.2d 1311, 1312 (9th Cir. 2012) (citations omitted).
resolving an ERISA benefits case on summary judgment when
applying the de novo standard, “the court may
conduct a trial on the administrative record.”
Id. at 1314. A trial on the administrative record
“permits the court to make factual findings, evaluate
credibility, and weigh evidence.” Id.
“When conducting a de novo review of the
record, the court does not give deference to the claim
administrator's decision, but rather determines in the
first instance if the claimant has adequately established
that he or she is disabled under the terms of the
plan.” Muniz v. Amec Construction Management,
Inc., 623 F.3d 1290, 1295-96 (9th Cir.2010).
“[T]he burden of proof is placed on the
claimant.” Id. at 1294.
the burden of proof, a plaintiff must establish “by a
preponderance of the evidence, that [she] was disabled under
the terms of the [p]lan during the claim period.”
Delaney v. Prudential Ins. Co. of America, 68
F.Supp.3d 1214, 1221 (D. Or. 2014) (citation omitted).
“To do so, she must ‘simply [persuade] the trier
of fact ... that the existence of a fact is more probable
than its nonexistence.'” Id. at 1221-22
(citing Concrete Pipe & Prods. of Cal., Inc. v.
Construction Laborers Pension Trust for S. Cal., 508
U.S. 602, 622, 113 S.Ct. 2264, 124 L.Ed.2d 539 (1993)
(additional citation omitted). “Unlike other standards
of proof ... the preponderance standard allows both parties
to share the risk of error in roughly equal fashion, except
that when the evidence is evenly balanced, the party with the
burden of persuasion must lose.” Id. at 1222
(citing Metro. Stevedore Co. v. Rambo, 521 U.S. 121,
137 n. 9, 117 S.Ct. 1953, 138 L.Ed.2d 327 (1997)).
parties stipulate that the standard of review is de
novo in this case. Pl.'s Mot. for J. 2 (ECF No. 20);
Def.'s Resp. and Mot. for J. 2 (ECF Nos. 23-24). The
Court reviews this case de novo and determines
whether Plaintiff has proffered evidence to show that it is
“more likely than not” that she was disabled.
See Sanchez v. Monumental Life Ins. Co., 102 F.3d
398, 404 (9th Cir. 1996) (“Under this burden [by a
preponderance of the evidence], the [party carrying the
burden] must provide evidence establishing that it is
‘more likely than not' ” that the disputed
fact is true as presented by the party carrying the burden);
see also Delaney, 68 F.Supp.3d at 1221-22.
Standard of Eligibility for Benefits
initial matter, Plaintiff notes that Metlife terminated her
benefits and denied her claim without evidence of
improvement. Pl.'s Mot. for J. 27 (ECF No. 20) (citing
Saffon v. Wells Fargo & Co. Long-Term
Disability Plan, 522 F.3d 863, 870 (9th Cir. 2008)
(where Metlife had been paying benefits for a year, which
suggests that plaintiff was already disabled, MRI scans
showing an improvement, not a lack of degeneration, would be
expected in order to find her no longer disabled.)). Metlife
distinguishes Saffon on the basis that
Saffon's termination decision was under a
uniform and unchanged disability standard, whereas the
standard to receive benefits here changed from
“own occupation” to the more stringent
“any occupation.” Def.'s Resp. and
Mot. for J. 26 (ECF Nos. 23-24) (emphasis added).
Specifically, the plan provides:
Disability or Disabled
means that as a result of Sickness or injury You are either
Totally Disabled or Partially Disabled.
Totally Disabled or Total
During the [365-day] Elimination Period and the next 24
months, You are unable to perform with reasonable continuity
the Substantial and Material Acts necessary to pursue
Your Usual Occupation in the usual and customary
After such period, You are not able to engage with reasonable
continuity in any occupation in which You could
reasonably be expected to perform satisfactorily in light of
• station in life; and
• physical and mental capacity
exists within any of the ...