Jones v. Metro. Life Ins. Co.

BOB G. JONES, Plaintiff,

v.METROPOLITAN LIFE INSURANCE CO., et al., Defendants.

CIVIL ACTION NO. H-12-1955

UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF TEXAS HOUSTON DIVISION

SIGNED: May 29, 2013

MEMORANDUM AND ORDER

This is a suit for benefits under an employee-welfare benefit plan (the "Plan") governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. The issue is remand to the Plan Administrator for consideration of information submitted after the administrative appeal ended. Based on the complaint, the motions, responses, and exhibits, the arguments of counsel, and the relevant law, this court grants the motion to remand. This suit is remanded to the plan administrator for 90 days to permit the Plan Administrator to consider evidence that was submitted after the administrative appeal ended. This case is stayed and administratively closed pending that review. The parties may reinstate this case to the active docket by filing a motion to do so within 14 days after the Plan Administrator concludes its review.

The reasons for this ruling are explained below.

I. Background

Bob Jones worked as an accountant for Lyondell Chemical Company from 1972 to 2009. Lyondell established the Plan to provide long-term disability ("LTD") benefits to its eligible employees. Lyondell is the Plan's sponsor and administrator. Lyondell self-funded the Plan,designated Metropolitan Life Insurance Co. ("MetLife") as the claims fiduciary, and granted MetLife discretionary authority to determine eligibility for Plan benefits and to interpret its terms.

In January 2010, Jones filed a claim for LTD fits under the Plan, claiming that he had become disabled in July 2009 due to severe chest pain. (Docket Entry No. 24, Appx., at 1-12). On February 25, 2010, MetLife informed Jones that it was denying his claim and described his appeal rights. (Id. at 13-17). Jones retained a lawyer, Tom Shipp, to represent him. In April 2010, Shipp appealed MetLife's denial on Jones's behalf and submitted records from two of Jones's treating physicians. (Id. at 18-19). MetLife sent Shipp a detailed report and a copy of MetLife's administrative claim file for Jones, which included the documents MetLife received from Shipp during the appeal process.

In an Agust 23, 2010 letter, MetLife provided a detailed synopsis of the medical information in the claim file and informed Shipp that it was upholding the denial of Jones's claim. The letter stated:

Upon request, MetLife will provide you with a copy of the documents, records or other information, we have that are relevant Mr. Jones's claim and identify any medical or vocational expert(s) whose advice was obtained in connection with his claim. You also have the right to bring [a] civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974.

Please be advised that under the provisions of Mr. Jones' Plan, no further administrative appeals are available to him concerning his disability benefit.

(Id. at 36).

The letter also stated:

Mr. Jones' file did not warrant further review by a board certifiedcardiologist in an effort to determine his functional limitation, as Dr. Uddin had explained several times during this appeal review that Mr. Jones' cardiac condition was stable and his chronic pain condition was not cardiac related. Please be advised, if additional medical information is submitted, by Dr. Uddin or any treating provider, in support of Mr. Jones functional limitations being related to his Coronary Artery Disease, we will be happy to review this information for consideration of benefits.

(Id. at 35-36).

On April 28, 2011, Adam Criaco, Jones's lawyer in this action, notified MetLife that he was representing Jones and asked about additional information or documentation needed for MetLife to complete its claim evaluation. (Id. at 37). MetLife responded as follows:

Please be advised the uphold determination of August 23, 2010 constituted completion of the full and fair review required by Mr. Jones' long term disability plan. Therefore, Mr. Jones already exhausted his administrative remedies under the plan and no further appeals will be considered.

Please be advised you have the right to bring [a] civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974.

Under the provision of Mr. Jones' Plan, no further administrative appeals are available to him concerning his disability benefit.

(Id. at 38).

In mid-June 2011, Criaco sent MetLife a series of letters requesting (among other things) the documents MetLife used to evaluate Jones's claim. (Id. at 39-42). In a letter dated July 12, 2011, MetLife sent Criaco a copy of the administrative claim file. (Id. at 43). Neither Jones nor Criaco sought to supplement the administrative record at that point. Instead, on August 8, 2011, Jones filed suit in the 152nd Judicial District Court of Harris County, Texas. (Id. at 44-62). The defendants removed the lawsuit to federal court, where it was docketed as Civil Action No. 4:11-cv-03328.

Jones served the defendants with written discovery and a copy of a subpoena that he had served on the Social Security Administration for a copy of its file on his claim for Social Security Disability Income ("SSDI") benefits. Before the initial pretrial and scheduling conference could occur, Jones voluntarily dismissed the suit. In a letter dated December 14, 2011, Criaco informed the defendants that Jones wanted to dismiss his pending action "[f]or personal reasons and time constraints." (Id. at 63). The next day, Jones filed an Unopposed Motion to Dismiss Without Prejudice, which was granted on December 16, 2011.

After the dismissal, Criaco sent MetLife additional documents in an attempt to supplement the administrative record. On January 6, 2012, Criaco sent defendants' counsel 280 pages of additional documents "offered for incorporation into the administrative record." (Id. at 64-70). Criaco explained that "[m]ost, if not all of the information and documentation that is attached for incorporation and re-evaluation was provided in some form or fashion in previous correspondence." (Id. at 70). Criaco included the following chronology of the documents:

+-----------------------------------------------------------------------------+
¦May 2007   ¦Dr. Ott and ¦Heart bypass. Coronary artery grafting Management   ¦
¦           ¦Pain        ¦Group at St. Lukes                                  ¦
+-----------+------------+----------------------------------------------------¦
¦2007       ¦Dr. Uddin   ¦Thallium Stress Test                                ¦
+-----------+------------+----------------------------------------------------¦
¦February   ¦Dr. Ott     ¦Chest X-Ray                                         ¦
¦2008       ¦            ¦                                                    ¦
+-----------+------------+----------------------------------------------------¦
¦June 2008  ¦Dr.         ¦Started pain management                             ¦
¦           ¦Singleton   ¦                                                    ¦
+-----------+------------+----------------------------------------------------¦
¦August 2008¦Dr. Uddin   ¦Thallium Stress Test                                ¦
+-----------+------------+----------------------------------------------------¦
¦February   ¦Dr. Uddin   ¦Heart Catheterization                               ¦
¦2009       ¦            ¦                                                    ¦
+-----------+------------+----------------------------------------------------¦
¦June-July  ¦Dr. Uddin   ¦External Contrapulsation Therapy (ECP)              ¦
¦2009       ¦            ¦                                                    ¦
+-----------+------------+----------------------------------------------------¦
¦July 10,   ¦Dr. Uddin   ¦Instructed not to return to work                    ¦
¦2009       ¦            ¦                                                    ¦
+-----------------------------------------------------------------------------+

+-----------------------------------------------------------------------------+
¦July 22, 2009   ¦Dr. Singleton ¦ESI injections at T7, T8, T9, T10            ¦
+----------------+--------------+---------------------------------------------¦
¦August 2009     ¦Dr. Ott       ¦Wire removal from 5/07 heart surgery         ¦
+----------------+--------------+---------------------------------------------¦
¦August 2009     ¦Dr. Ott       ¦CAT scan                                     ¦
+----------------+--------------+---------------------------------------------¦
¦September 23,   ¦Dr. Singleton ¦ESI injections at T7, T8, T9, T10            ¦
¦2009            ¦              ¦                                             ¦
+----------------+--------------+---------------------------------------------¦
¦September 23,   ¦Dr. Singleton ¦ESI injections at T7, T8, T9, T10            ¦
¦2009            ¦              ¦                                             ¦
+----------------+--------------+---------------------------------------------¦
¦October 2009    ¦Dr. Singleton ¦Referred to Dr. Phan for neurostimulator     ¦
+----------------+--------------+---------------------------------------------¦
¦December 2009   ¦Steve Smith,  ¦Psychological Exam related to neurostimulator¦
¦                ¦PhD           ¦                                             ¦
+----------------+--------------+---------------------------------------------¦
¦January 2010    ¦              ¦Heath insurance (Aetna) denied               ¦
¦                ¦              ¦neurostimulator                              ¦
+----------------+--------------+---------------------------------------------¦
¦December 1, 2010¦              ¦Aetna reversed decision for neurostimulator  ¦
+----------------+--------------+---------------------------------------------¦
¦December 22,    ¦Dr. Phan      ¦Trial neurostimulator (dorsal column         ¦
¦2010

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