TERESA A. SEEMAN, Plaintiff,
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.
On April 19, 2012, the plaintiff, Teresa A. Seeman ("Seeman"), brought this action against the defendant, Metropolitan Life Insurance Company ("MetLife"), the fiduciary and administrator of the Bank of America Long-Term Disability Plan (the "Plan"), seeking the payment of allegedly past-due benefits and a determination of her rights to ongoing benefits.(D.I. 1 at If 14.) Presently before the court are the parties' March 19, 2013 cross-motions for summary judgment (D.I. 16; D.I. 20). Both motions have been fully briefed, and, for the reasons that follow, the court will deny MetLife's Motion for Summary Judgment (D.I. 16) and grant Seeman's Motion for Summary Judgment (D.I. 20).
The Plan is an employee welfare benefit plan governed by ERISA that provides long-term disability benefits ("LTD benefits") to qualified participants. (D.I. 1; D.I. 17 at 3.) MetLife served as both the fiduciary and claim administrator of the Plan. (D.I. 17 at 3; D.I. 18 at 11.) The Plan defines "disability" as follows:
"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 unless, in the opinion of a Doctor, future or continued treatment would be of no benefit; and
1. During the first 24 months, excluding your Elimination Period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own Occupation for any employer in your Local Economy; or
2. After the first 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 reasonably qualified taking into account your training, education, experience and Predisability Earnings.
(D.I. 18 at 27.) The Plan, however, also imposes certain restrictions on eligibility for LTD benefits through the following "Limitation for Disability Due to Particular Conditions" provision:
You are covered for 24 months of Disability, including Elimination Period(s), during your lifetime if you are Disabled due to a Mental or Nervous Disorder or Disease, unless the Disability results from:
2. Bipolar disorder;
3. Dementia; or
4. Organic brain disease.
"Mental or Nervous Disorder or Disease" means a medical condition of sufficient severity to meet the diagnostic criteria established in the current Diagnostic And Statistical Manual of Mental Disorders. You must be receiving Appropriate Care and Treatment for your condition by a mental health Doctor. In no event will Monthly Benefits be payable longer than the Maximum Benefit Duration shown in the Plan Highlights.
(Id. at 34.) Finally, the Plan provides that benefit payments end on the earliest of (1) the end of the "Maximum Benefit Duration, " (2) the end of the period set forth in the "Limitation for Disabilities Due to Particular Conditions" section or the "Limitation for Alcohol, Drug or Substance Abuse or Dependency" section, (3) the date on which the participant is no longer "disabled, " as defined above, (4) the date on which the participant fails to provide information listed in the "Plan Highlights" section, (5) the date of the participant's death, or (6) the date on which the participant fails to attend a medical examination requested by MetLife. (Id. at 26.)
In 2007, Seeman was a First Vice President/Unit Manager II at Bank of America and a participant in the Plan. (Id. at 1; D.I. 21 at 3.) She was diagnosed with infectious mononucleosis in December 2007 with symptoms of fever, extreme fatigue, trouble breathing, flu-like symptoms, inability to concentrate, and inability to sleep. (D.I. 21 at 3.) Seeman submitted a claim for and received short-term disability benefits from December 5, 2007 until June 3, 2008. (Id.; D.I. 19 at 1671.) Seeman then applied for LTD benefits, and MetLife approved her application, making her eligible for LTD benefits effective June 4, 2008. (D.I. 19 at 1530; D.I. 21 at 3.)
Seeman received LTD benefits from June 4, 2008 through July 16, 2010, when MetLife informed Seeman by letter that her benefits had been terminated. (D.I. 17 at 5; D.I. 19 at 998; D.I. 21 at 5.) MetLife's termination decision was based upon its review of Seeman's medical records and a Neuropsychological Testing Report prepared by Dr. Glen Greenberg (the "Greenberg report"), following a June 11, 2010 independent medical examination. (D.I. 19 at 1000.) In it July 16, 2010 termination letter, MetLife made the following observations regarding the medical record:
(1) While Dr. James Berlin, Seeman's primary care physician, concluded that Seeman was disabled, "there is no clinical evidence to support his assessment." (Mat 1000.)
(2) While Seeman treated with Dr. John Reinhardt, an infectious disease specialist, for chronic fatigue, [tempromandibular joint disorder ("TMJ")], and fibromyalgia, Dr. Reinhardt commented that he was unsure whether Seeman qualified for disability. (Id.)
(3) Dr. Susan Epps, Seeman's psychologist, disgnosed her with "Major Depression and Generalized Anxiety Disorder" and "Post-Traumatic Stress Disorder." (Id.)
(4) Dr. Monica Snowden, . Seeman's rheumatologist, "indicated that [Seeman's] diagnosis of fibromyalgia is a component of [her] medical condition, but is not [her] primary health concern." (Id.) "Dr. Snowden also noted that [Seeman] failed to respond to the drugs she has offered . . . and that she suspects [Seeman] may have gotten to this point due to lack of sleep, depression and family stresses." (Id.)
(5) Dr. Michael Carunchio, Seeman's neurologist, "noted memory loss and recommended a brain MRI, which came back normal, along with a neuropsychological exam." (Id. at 999.)
Additionally, MetLife noted that the Greenberg report diagnosed Seeman with "Undifferentiated Somatoform Disorder, Major Depressive Disorder, Single Episode, R/O Anxiety Disorder and Obsessive-Compulsive Personality traits." (Id. at 1000.) The termination letter proceeded to explain that "[somatoform disorders arise from psychological conflicts or issues that manifest and present with physical symptoms, " and that "[t]hey can also arise with depression, which may be present, in [Seeman's] case." (Id. at 1001.) On this basis, the Greenberg report concluded that Seeman's "impairment exists due to psychiatric reasons and not neurological ones." (Id. at 1002.) MetLife's July 16, 2010 letter stated that the Greenberg report was "consistent" with the collective findings of Seeman's treating physicians, which revealed "an emphasis on psychological factors giving rise to or exacerbating the physical and cognitive complaints." (Id.)
Supposedly on the basis of the Greenberg report and the medical records, MetLife thus characterized Seeman's disability as resulting from a "Mental or Nervous Condition" under the "Limitation for Disability Due to Particular Conditions" provision rather than from any physical ailment. (D.I. 17 at 5.) As indicated above, the Plan generally limits ...