Driscoll v. MetLife Ins.

BRIAN JOSEPH DRISCOLL, Plaintiff, v. METLIFE INSURANCE; ANHEUSER-BUSCH INBEV INC.;and DOES 1 to 100 Defendants.

Case No.: 15-CV-1162 JLS (LL)

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF CALIFORNIA

November 6, 2020

ORDER: (1) GRANTING DEFENDANT'S MOTION FOR JUDGMENT, AND (2) DENYING PLAINTIFF'S MOTION FOR JUDGMENT

(ECF Nos. 107, 118)

Presently before the Court are Plaintiff Brian Driscoll's ("Pl.'s Mot.," ECF No. 118¹) and Defendants Metropolitan Life Insurance Co. ("MetLife") and Anheuser-Busch Companies, LLC's ("A-BC") ("Defs.' Mot.," ECF No. 107) cross-motions for judgment. The Court concludes that this matter is capable of resolution on the papers and without oral argument pursuant to Civil Local Rule 7.1(d)(1). Having carefully considered the Parties' arguments, the Plan (ECF No. 61-4), the Administrative Record ("AR," ECF Nos. 61-5-42), and the law, the Court GRANTS Defendants' Motion and DENIES Plaintiff's Motion.

FINDINGS OF FACT

I. The Plan and Relevant Terms

MetLife issued a group certificate of insurance to A-BC, funding an employee welfare benefit plan (the "Plan"), see generally PLAN,² governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq. ("ERISA"). See PLAN 56. Pursuant to the Plan, A-BC was the plan administrator, see PLAN 54, while Defendant MetLife was the claims administrator, see PLAN 55-56.

Among other benefits, the Plan provides for long-term disability ("LTD") benefits for eligible participants who become disabled as defined by the Plan and remain disabled throughout the entirety of a 180-day Elimination Period and each month thereafter for which disability benefits are sought. See PLAN 35-37. The Plan defines "Disabled or Disability" as follows:

Disabled or Disability means that, due to Sickness or as a direct result of accidental injury:

• You are receiving Appropriate Care and Treatment determined by Your Physician as necessary to treat the Sickness or injury;

• You are complying with the requirements of such treatment; and

• You are unable to earn:

• during the Elimination Period and the next 24 months of Sickness or accidental injury, more than 80% of Your Predisability Earnings or adjusted Predisability Earnings at Your Regular Occupation from any employer in Your Local Economy; and

• after such period, more than 80% of Your Predisability Earnings or adjusted PredisabilityEarnings from any employer in Your Local Economy at any gainful occupation for which You are reasonably qualified taking into account Your training, education and experience.

PLAN 23 (emphasis in original). The Plan requires a claimant to submit proof, "at the claimant's expense," PLAN 26, that he or she is Disabled as defined in the Plan, PLAN 35. The Plan defines "Proof" as:

Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish:

• the nature and extent of the loss or condition;

• Our obligation to pay the claim; and

• the claimant's right to receive payment.

PLAN 26.

The Plan sets forth terms for claim submission, determination, and appeal. See PLAN 55-56. Following submission of an initial claim, "notification [is to] be provided to [the claimant] within a reasonable period, not to exceed 45 days from the date [the claimant] submitted [his or her] claim; except for situations requiring an extension of time because of matters beyond the control of the Plan, in which case MetLife may have up to two (2) additional extensions of 30 days each to provide [the claimant] such notification." PLAN 55. "If MetLife needs an extension, it [is to] notify [the claimant] prior to the expiration of the initial 45 day period (or prior to the expiration of the first 30 day extension period if a second 30 day extension period is needed), state the reason why the extension is needed, and state when it will make its determination." Id.

In the event of a denial, the claimant is entitled to appeal the decision. Id. "After MetLife receives [a claimant's] written request appealing the initial determination, MetLife [is to] conduct a full and fair review." PLAN 56. "Deference [is] not . . . given to the initial denial, and MetLife's review . . . look[s] at the claim anew." Id. "The review on appeal . . . takes into account all comments, documents, records, and other information that[the claimant] submit[s] relating to [his or her] claim." Id. "If the initial denial is based in whole or in part on a medical judgment, MetLife . . . consult[s] with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment." Id. "MetLife [is to] notify [the claimant] in writing of its final decision within a reasonable period of time, but no later than 45 days after MetLife's receipt of [the claimant's] written request for review, except that under special circumstances MetLife may have up to an additional 45 days to provide written notification of the final decision." Id. "If such an extension is required, MetLife [is to] notify [the claimant] prior to the expiration of the initial 45 day period, state the reason(s) why such an extension is needed, and state when it will make its determination." Id. "If an extension is needed because [the claimant] did not provide sufficient information, the time period from MetLife's notice to [the claimant] of the need for an extension to when MetLife receives the requested information does not count toward the time MetLife is allowed to notify [the claimant] of its final decision." Id. "If MetLife denies the claim on appeal, MetLife [is to] send [the claimant] a final written decision that states the reason(s) why the claim [the claimant] appealed is being denied and reference[] any specific Plan provision(s) on which the denial is based." Id.

Under the terms of the Plan, "the Plan Administrator and other Plan fiduciaries (which shall include MetLife as the Claim Fiduciary) shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan." Id. Further, "[a]ny interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious." Id.

Pursuant to ERISA, all participants in the Plan are entitled to "[o]btain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan descriptions." PLAN 57.

II. Plaintiff's Employment

Plaintiff worked as a Warehouse Manager for A-BC from November 4, 1989, until August 9, 2014. See, e.g., AR 838.³ As a Warehouse Manager, Plaintiff often worked ten-hour days, with his major roles including "receiving/UPS/unloading/loading in bulk, building and loading customer orders six days a week, checking in and out up-to 60 truck drivers and 20-30 contract truck drivers, [and] reprocessing damaged product." See, e.g., AR 1820. Plaintiff's position also included responsibilities of the facility manager, material handling, and safety manager. See id. Facilities management involved "building and office housekeeping, maintenance and contracted services," while material handling involved "batteries, forklifts and walkie-riders (electronic stand-up forklift-type equipment), and specialized railroad guided forklift." Id.

According to Defendants, Plaintiff's position "involved frequent standing, walking, bending, squatting, [and] trunk rotation[;] occasional sitting, climbing, balancing, crawling, and driving[;] and . . . work at heights and . . . around moving mechanical parts." AR 838; see also AR 3540-3541. The demands of Plaintiff's position were classified as "very heavy." AR 855; see also AR 3540.

III. Plaintiff's Claims for Benefits and MetLife's Denials

Plaintiff took a leave of absence from work between January 23 and February 9, 2014. AR 1787. He filed claim 711401298061 for LTD benefits with MetLife on January 30, 2014 (the "First Claim"). AR 3660. Plaintiff's First Claim was denied when he returned to work on February 10, 2014. AR 3668-3669.

Plaintiff took a second leave of absence from work beginning March 3, 2014, but he returned to work on May 20, 2014. AR 1787. He went on disability beginning August 9, 2014. Id. On August 12, 2014, Plaintiff renewed his First Claim with MetLife seeking LTD benefits as of August 10, 2014. AR 3672-3673, 3686. He submitted a formal claimon August 26, 2014, AR 3247-3264, which was assigned claim number 741408156858 (the "Second Claim"), see AR 3686; see also AR 3673. In the paperwork, he described his symptoms as "di[zziness], nausea, ringing in ear, ear pressure, fatigue, high [blood pressure], palp[i]tations, [irritable bowel syndrome], difficulty recalling names [and] facts, math difficult[y]." AR 3252. He identified his attending physicians as follows: Dr. Michael Rogers, primary care physician; Dr. Christopher Trent, otorhinolaryngologist; Dr. Prasanth Mathena, neurologist; and Dr. William Go, gastroenterologist. Id. He also listed a number of medications he was taking for his condition. Id.

Following receipt of Plaintiff's medical records, a nurse consultant at MetLife performed a review on December 16, 2014. AR 3722-3731. On December 19, 2014, the nurse consultant called Plaintiff to discuss his claim and his condition. AR 3731-3737. Later that day, the nurse consultant discussed Plaintiff's file with MetLife's Medical Director. AR 3741-3743. She then placed a note in his file indicating that the available medical information did not support disability, but recommending a reevaluation following review by nontreating physicians:

In my opinion, [t]he available medical information submitted

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