Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Medefesser v. Metropolitan Life Insurance Co.

United States District Court, D. Oregon, Eugene Division

September 5, 2019

JANE A. MEDEFESSER, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

          FINDINGS AND RECOMMENDATION

          MUSTAFA T. KASUBHAI UNITED STATES MAGISTRATE JUDGE

         Plaintiff, 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.

         For the 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.

         BACKGROUND

         Plaintiff 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.

         Plaintiff 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.

         Metlife 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 1206.

         On February 22, 2016, Metlife approved Plaintiff's LTD benefits under the “own occupation” standard following Dr. Schmidt's opinion. AR 1162-64, 1172.

         On July 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.

         On 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 status.” Id.

         Metlife 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.

         Metlife upheld its decision to terminate benefits following its review of Plaintiff's appeal. AR 653-60. Plaintiff filed this action.

         STANDARD OF REVIEW

         “[A] 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).

         In 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.

         To meet 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)).

         DISCUSSION

         The 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.

         I. Standard of Eligibility for Benefits

         As an 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 Disability means:
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 way.
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 Your:
• age;
• education;
• training;
• experience;
• station in life; and
• physical and mental capacity

         that exists within any of the ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.