Candelaria v. Met Life Ins. Co.

SYLVIA CANDELARIA, Plaintiff,

v.MET LIFE INSURANCE COMPANY Defendant.

No. 10-CV-726 JEC/DJS

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

Dated: August 29, 2011

MEMORANDUM OPINION AND ORDER

THIS MATTER comes before the Court on Plaintiff's Motion to Reverse ERISA LTD Insurer's Benefit Termination, filed November 19, 2010 (Doc. 20) ("Motion"), and Defendant's Opposition to Plaintiff's Motion to Reverse ERISA Determination and Cross-Motion for Summary Judgment on MetLife's Claim for Reimbursement, filed January 14, 2011 (Doc. 40) ("Response"). Having reviewed the pleadings, the administrative record, the governing authority, and being otherwise fully informed, the Court will grant Plaintiff's Motion in part such that the case will be remanded to the plan administrator for further findings, and deny the Motion in part as to Plaintiff's request for entry of judgment in her favor. Defendant's Cross-Motion will be denied as moot.

I. Background

This case arises under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. Plaintiff, Sylvia Candelaria, was employed by CitiCards as a telephone collector. Through this employment, Plaintiff participated in a disability insurance plan ("Plan"), issued and administered by MetLife Insurance Company ("Defendant"). Plaintiffreceived both short-term disability ("STD") and long-term disability ("LTD") benefit payments until May 15, 2009, when Defendant determined that she no longer qualified as disabled under the Plan. Defendant appealed through the administrative process provided under ERISA, and Defendant denied Plaintiff's appeal on November 17, 2009. On June 28, 2010, Plaintiff timely filed a complaint in New Mexico state court, alleging a breach of the Plan, and Defendant removed the action under ERISA to this Court on August 3, 2010.

A. Approval of STD Benefits

In the summer of 2008, Plaintiff began to experience severe, chronic headaches, and on July 18, 2008, she ceased work upon the advice of Dr. Montoya, her primary care physician. Administrative Record ("AR")¹ at 275. Plaintiff was approved for STD benefits on August 14, 2008, retroactive to July 18, 2008, the day after her last work day, through August 7, 2009. AR 270. On August 22, 2008, Dr. Dvorak, a family practitioner, informed Defendant that he had treated Plaintiff for chronic severe headaches, phonophobia and photophobia, that she had a suboccipital block performed by Dr. Wagner, a pain management specialist in his office, and that she was unable to work. AR 216-217. Defendant approved STD benefits through September 22, 2008, "based on ongoing severity of [of headaches] with photo/phono phobia..." and "need for ablation treatment as well as ongoing use of narcotic pain med[ication] which would preclude even sedentary work." AR 223. On September 22, 2008, Dr. Dvorak again advised Defendant that Plaintiff was unable to return to work due to persistent and constant headaches, rendering her unable to concentrate, and photophobia and phonophobia. AR 226-227. Defendant extendedher STD benefits through October 5, 2008. AR 230. Defendant subsequently attempted to obtain medical information from Dr. Wagner but was unsuccessful. AR 232-236. On October 22, 2008, Dr. Montoya informed Defendant that he was handling Plaintiff's treatment because Dr. Wagner "will not," and Dr. Dvorak was not currently practicing. AR 237. Dr. Montoya agreed to provide Defendant with Dr. Wagner's records of the occipital blocks performed on Plaintiff on October 6 and 13, 2008. AR 237.

On October 28, 2008, Dr. Montoya diagnosed Plaintiff with depressive disorder and intractable variant migraines, noting a long history of migraines with an acute worsening since July. AR 113. Dr. Montoya added that Plaintiff's pain specialist had sent her for interventional approaches and wanted to "do a [radio frequency] ablation of her cervical group," but that she needed to extend her disability to get the procedure done. Id. On October 28, 2008, Defendant determined that the ongoing severity of functional impairment qualified Plaintiff for benefits through October 16, 2008, the maximum time allowed for her STD benefits. R. 241-242. In its claim activity log, Defendant noted that "based on the ongoing severity of pain," there was "need for change in prophylactic medication and cervical branch block; time for therapeutic effect to be achieved; [and] medical [follow-up] for reeval[uation] with possible radio-frequency ablation procedure to be done, if no relief from injection therapy." AR 242. Defendant added that "[i]t is reasonable to expect that ongoing severity of pain with [history] of cervical muscle tightness and photophobia would preclude [employee] from safely performing her job until reeval[uation] for effectiveness of new treatment is completed." Id. The file was then transitioned for review of LTD benefits.

B. Initial Approval of LTD Benefits

On October 30, 2008, after review by nurse and vocational rehabilitation consultants, Defendant determined that Plaintiff qualified for LTD benefits, and identified Plaintiff's potential candidacy for a radio-frequency ablation procedure, should injection therapy fail, and the need to obtain clinical examination findings for review. AR 245-246. By letter of November 4, 2008, Defendant informed Plaintiff that she was approved for LTD benefits. AR 178. The letter quotes the Plan's definition of long term disability as follows:

... [C]lass I ... 'Disabled' or 'Disability' means that, due to sickness,

pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis; and

a. during your Elimination Period and the next 24 month period, you are unable to earn 80% of your Pre-disability Earnings at your Own Occupation for any employer in your Local Economy;

b. after the 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 reasonable [sic] qualified taking into account your training, education, experience and Predisability Earnings.

AR 174.

The same letter also states:

If you remain out of work until January 18, 2009, you are required to apply for Social Security Disability Insurance (SSDI) benefits. When you apply for SSDI benefits, please request a receipt of application and mail a copy to our office.

AR 175.

Defendant also enclosed a number of forms in the letter, including documents entitled Personal Profile and Employee Statement ("Statement"), Authorization to Refer Me to a Law Firm for Assistance in Pursuing Social Security Insurance Benefits ("Authorization"), Metropolitan Life Insurance Consent for Release of Social Security Information ("Consent"), and a Long Term Disability Reimbursement Agreement ("Reimbursement Agreement"), for Plaintiff to complete and return by November 20, 2008. AR 178-197.

On November 12, 2008, Dr. Montoya diagnosed Plaintiff with chronic, intractable migraines and reactive depression to chronic pain, observing that she had failed injections and medication modifications, was "narcotic dependent," and crying throughout the exam. AR 114. Dr. Montoya stated that he could not predict long term disability until Plaintiff had a "pain procedure" at New Mexico Pain and Wellness, and that he did not add new medication "since most had failed." Id.

On or about December 16, 2008, Plaintiff returned the forms she received from Defendant, including her Statement that she suffered from headaches and neck pain due to osteoarthritis, had to force herself to walk and do things in the dark due to pain, and needed help with personal needs and grooming. AR 161-162. Plaintiff also stated that she couldn't return to work, even with an accommodation, because she was having a hard time focusing due to extreme pain. AR 163. Plaintiff returned a signed Reimbursement Agreement in which she agreed to apply for SSD benefits and provide Defendant with "proof" of having done so; appeal a denial of her SSA claim; and reimburse Defendant in a single lump sum payment for any overpayment made to her due to the integration of retroactive SSD benefits. AR 160. No medical records were included with the forms Plaintiff returned. AR 159-177.

C. Investigation of Plaintiff's Continued Eligibility for LTD Benefits

On December 29, 2008, Plaintiff informed Defendant that she was still "not doing better," that the Botox injection she had received to treat her headaches did not "hit the right area," and that she was "going to pursue a lawsuit against Dr. Wagner as all [he] is having her do is taking pain killers." AR 8. On that date, Defendant faxed a Physician Questionnaire ("Questionnaire") to Dr. Montoya requesting records from Plaintiff's last three visits with him. AR 155-158. On January 3, 2009, Dr. Montoya returned the Questionnaire, diagnosing Plaintiffwith "migraine intractable" and a secondary diagnosis of depression, and stating she could not function or concentrate, was taking narcotics continuously, and could not tolerate florescent lights or computer screens. AR 151. Dr. Montoya further opined that he could not estimate a return to work date, and that a functional capacity evaluation ("FCE") needed to be performed as well as clearance by a pain specialist. AR 151-152. No medical records were attached to the returned Questionnaire. AR 155-158. In January and April of 2009, Defendant faxed questionnaires to Dr. Wagner inquiring about treatment, but received no response, despite stating that failure to respond could impact Plaintiff's disability benefits. AR 146, 128.

At some point during the claim administration, Plaintiff applied for SSDI benefits and on February 26, 2009, Defendant contacted Plaintiff to discuss the status of her SSD claim. AR 140. On March 9, 2009, the Social Security Administration ("SSA") notified Plaintiff of its conclusion that she was disabled and entitled to monthly benefits in the...