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Ansari v. Metropolitan Life Insurance Co.

United States District Court, D. Massachusetts

December 11, 2014

ELEANOR ANSARI, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

MEMORANDUM AND ORDER REGARDING CROSS-MOTIONS FOR JUDGMENT ON THE PLEADINGS (Document Nos. 29 and 33)

KENNETH P. NEIMAN, Magistrate Judge.

Eleanor Ansari ("Plaintiff") brings the instant action pursuant to the Employment Retirement Security Income Act ("ERISA"), 29 U.S.C. § 1001 et seq, seeking judicial review of a decision denying her long-term disability benefits ("LTD") by Metropolitan Life Insurance Company ("Defendant"), the issuer and claims administrator of her employer's benefits plan. Count 1 of the complaint concerns the LTD denial and Count 3 concerns damages stemming from that denial. Plaintiff also alleges, in Count 2, that Defendant failed to provide her with adequate documentation of the LTD Plan ("Plan") in violation of 29 U.S.C. § 1132(c)(1)(B).

Presently, Plaintiff moves for judgment on the administrative record, arguing that Defendant failed to provide Plan documentation and that, in any event, Defendant's decision to deny her LTD benefits was neither reasonable nor supported by substantial evidence. Defendant cross-moves for relief in its favor, contending that its decision was reasonable and adequately supported and, as well, that it had no duty to provide Plan documentation. For the reasons which follow, the court will deny Plaintiff's motion and grant Defendant's motion for judgment on the record.

I. BACKGROUND

A. The Plan

The Plan provides for LTD benefits to certain employees of Verizon Wireless who qualify as disabled. It grants Defendant discretionary authority to interpret its terms, including determining eligibility for and entitlement to Plan benefits. (Administrative Record ("A.R.") at 49, 80.) Employees are disabled under the Plan for the first 24-month "qualifying period" if they cannot earn more than 80 percent of their pre-disability earnings at their actual occupation from any employer in the local economy. (Id. at 18.) After those first 24 months, employees, to receive further LTD benefits, are evaluated under a higher disability standard, that is, the inability to earn more than 60 percent of their pre-disability earnings at any gainful occupation in the local economy for which they are reasonably qualified. (Id.)

B. Plaintiff's Claim for LTD Benefits

Plaintiff worked as a supervisor at Verizon Wireless, a position that required six to eight hours of standing and walking per day, when she developed a "hammer toe."[1] (Id. at 195, 821.) As a full-time employee, Plaintiff was entitled to participate in its disability benefits plan. (Id. at 102.) On February 26, 2010, her podiatrist, Dr. William Axton, performed corrective surgery on her toe. (Id. at 821.) On March 19, 2010, Defendant approved Plaintiff's initial claim for short-term disability benefits; it would ultimately afford her the maximum of 26 weeks of full pay to recover from the surgery, based on her length of service. (Id. at 63, 675.)

Plaintiff's surgery, however, did not cure all of her pain and, in fact, may have caused or aggravated an independent painful condition in the same region of her body. (Id. at 817.) In her fourth post-operative visit with Dr. Axton, she complained that her "left foot [was] still very painful and ting[ling] and numb." (Id.) Dr. Axton noted that she was possibly suffering from chronic regional pain syndrome ("CRPS") in her left foot and referred her to a pain management specialist.[2] (Id.)

On May 7, 2010, Plaintiff's pain management specialist gave her a lumbar sympathetic block injection. (Id. at 344.) She soon returned to Dr. Axton, however, complaining of side-effects from the block and stating that she still suffered pain in her foot. (Id. at 786-787.) Dr. Axton pressed her to retry pain management and noted that she still could not work. (Id.)

On June 1, 2010, Plaintiff saw Drs. William Thompson and Shameema Faruqi, both pain management specialists, who determined that she still suffered from left foot pain "both somatic and neuropathically induced, " increased her dose of gabopentin, and suggested physical therapy and the possibility of a future nerve block. (Id. at 343.) She returned again to Dr. Axton on June 18, complaining that she could not stand for more than thirty minutes. (Id. at 778.) Dr. Axton noted that her complaints were consistent with CRPS. Later that month, Plaintiff followed up with Dr. Thompson, who noted that "CRPS type one is likely." (Id. at 587.) Similarly, on August 19, 2010, a third doctor at the pain management clinic, Poornachandra Manikantan, concurred that Plaintiff had "features of neuropathic/CRPS kind of pain in the left foot." (Id. at 338.)

Plaintiff's condition did not improve. Accordingly, Defendant determined that Plaintiff met the requirements for the two-year LTD qualifying period and she began receiving those benefits on August 27, 2010, the day after she exhausted her short-term disability benefits. (Id. at 454, 946.) Defendant thereafter reviewed Plaintiff's condition semiannually and continued to approve her for LTD at the lower, qualifying period, standard. (Id. at 959-62, 977.) On October 8, 2010, Dr. Axton again noted Plaintiff's complaints of pain and maintained his diagnosis of CRPS. (Id. at 577-78.)

On February 28, 2011, however, a bone scan recommended by Dr. Manikantan failed to produce objective evidence of CRPS. (Id. at 437.) And while, on several occasions, Dr. Axton observed inconsistencies in Plaintiff's skin temperature in the affected area - an objective sign of CRPS - Dr. Manikantan found that her temperature was "equal bilaterally." (Id. at 332, 540, 542-43.) Dr. Manikantan also recorded that Plaintiff's foot pain increased with activity and decreased with elevation. (Id. at 346.)

On August 13, 2011, nearly halfway through Plaintiff's qualifying period for LTD, the Social Security Administration ("SSA") approved her application for Social Security Disability Benefits ("SSDI") after an initial denial. (Id. at 547, 572.) The SSA found that Plaintiff was disabled starting on July 22, 2011, but, pursuant to SSA rules, was not entitled to collect those benefits until January 2012. (Id. at 548.)[3] Except for Plaintiff's initial denial and subsequent award letters, there is no documentation from her SSDI claim file in the administrative record before the court. (Id.)

As Plaintiff's LTD qualifying period came to a close, the question of whether she would be eligible for permanent LTD began to loom over the horizon. To that end, on February 9, 2012, after several more visits with Plaintiff, Dr. Axton completed a form, titled Physical Capacity Evaluation, provided by Defendant. (Id. at 467-469.) Therein, Dr. Axton produced the following information:

In an 8 hour day of How many minutes in an How many hours in a activity, the patient can: hour? day? Sit 20-30 4-6 Stand 10-15 1-2 Walk ...


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