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Daly v. Metropolitan Life Insurance Company

United States District Court, D. Delaware

October 1, 2018


          Marc H. Snyder, Kelly Anne Parry Inverso, ROSS, MOSS, SNYDER& BLEEFELD, LLP, Wilmington, DE Attorneys for Plaintiff Conlan Daly, as Designated Life Insurance Beneficiary of Thomas Daly (Plan No. 10186)

          David P. Primack, Randi F. Knepper, MCELROY, DEUTSCH, MULVANEY & CARPENTER LLP, Wilmington, DE Attorneys for Defendant Metropolitan Life Insurance Company


          STARK, U.S. District Judge.

         Plaintiff Thomas Daly[1] (“Daly” or “Plaintiff”) sued Defendant Metropolitan Life Insurance Company (“MetLife” or “Defendant”), alleging claims pursuant to the Employment Retirement Income and Security Act of 1974 (“ERISA”), as amended, 29 U.S.C. §§ 1001-1461. (D.I. 1) Plaintiff seeks recovery of long-term disability benefits allegedly due under a policy of insurance issued by Defendant to Plaintiff's employer as well as recovery of costs and attorneys' fees as provided by ERISA. (Id. ¶¶ 37-41, 62) The parties agreed that the case could be decided on cross-motions for summary judgment without conducting any additional discovery. (See D.I. 9) Such motions are now pending before the Court and are fully briefed.[2] (See D.I. 15-18, 20-23, 25) For the reasons stated below, the Court will grant Defendant's Motion (D.I. 15) and deny Plaintiff's Motion (D.I. 21).

         I. BACKGROUND

         A. General Background

         The complaint alleges that “[t]he medical records reflect that, beginning in or about March 2013, Mr. Daly had been suffering from increasingly constant and severe lumbar spine pain and lower extremity pain and symptoms; having been diagnosed as suffering from “significant scoliosis with spondylolisthesis and root compression.” (D.I. 1 ¶ 14) (emphasis added by Plaintiff)

         The complaint further alleges that “Mr. Daly's total disability status from March 2013 and ongoing have been continually supported by his medical specialists who have been treating him for chronic, debilitating lumbar spine injuries and pain, with corresponding severe lower extremity radiculopathy.” (Id. ¶ 15)

         According to the complaint, Plaintiff was eligible for benefits under an insurance plan administered by MetLife. (Id. ¶¶ 7-12) Plaintiff applied for benefits under the plan based on his medical condition and MetLife denied the claim. (Id. ¶¶ 13-36) Plaintiff alleges MetLife violated ERISA and wrongfully terminated his claim for benefits. (Id. ¶¶ 37-65)

         B. Plaintiff's Claim for Disability Benefits

         Plaintiff was employed as a Software Salesperson for Oracle U.S.A. Inc.. (D.I. 1 ¶ 3) As an employee, Plaintiff was a participant in the Basic and Optional Employee Life Continued Protection under Oracle's policy of insurance (the “Plan”) issued and administered by Defendant. (Id.) Plaintiff was enrolled for $50, 000 of basic life insurance and $1, 542, 000 in supplemental life insurance. (Id. ¶ 9) The Plan provided for continuation of insurance while a participant has “Total Disability” or is “Totally Disabled, ” which the Plan defined as follows: “because of a sickness or an injury: you cannot do your job; and you cannot do any other job for which you are fit by your education, your training or your experience.” (Id. ¶ 10)

         Plaintiff submitted a claim that he was Totally Disabled as of March 5, 2013. (D.I. 12 MET/DALY/AR-31) Plaintiff stated that he had back pain, was not “able to engage in any gainful occupation, ” and does not expect to return to work. (Id.) Plaintiff's physician, Dr. Domingo C. Singson, provided a statement showing Plaintiff's diagnosis was “lumbar disc herniation” and “sciatica.” (Id. MET/DALY/AR-33) As to Plaintiff's physical capabilities, Dr.

         Singson noted Plaintiff was able to continuously sit, stand, or walk for “0” hours. (Id. MET/DALY/AR-34) On the extent of disability, Dr. Singson noted Plaintiff was “totally disabled, ” could not perform his regular occupation or any other occupation, and expects Plaintiff to “never” be able to “resume any work.” (Id.) The doctor also expected Plaintiff would be having “lumbar surgery.” (Id.)

         C. MetLife's Initial Denial

         In a letter dated September 19, 2013, MetLife notified Plaintiff it had denied his claim because Plaintiff “d[id] not meet the definition of disability as defined in [his] Plan.” (D.I. 1-1 at 1) MetLife's denial letter stated that “[a]fter reviewing everything in your file, we conclude that the information does not support a severe functional impairment that would preclude your ability to return to work as defined by the plan.” (Id. at 2) The letter further noted that “the definition of disability requires that you be unable to perform any occupation. Your current residual functional abilities are unclear from the limited medical provided.” (Id. at 2) Plaintiff's file included documentation and medical records dated between May and July 2013. (See e.g., D.I. 12 MET/DALY/AR-422-47) MetLife's review of Plaintiff's file included a review by MetLife's Nurse Consultant, who concluded that “the information submitted does not adequately support a functional impairment precluding your ability to return to work in any capacity.” (Id. MET/DALY/AR-18)

         The Nurse Consultant reviewed the office visit notes from Plaintiff's primary care physician, Dr. Singson, Plaintiff's neurosurgeon, Dr. Rastogi, and Plaintiff's own description of pain. (Id.) Based on this review, the Nurse Consultant noted that the restrictions and limitations of “zero functions in all areas” indicated by Dr. Singson are “not medically supported, ” in part because his office visit notes dating from March to April 2013 reported “back pain only mild to moderate and medications [were] effective, ” which also contradicted Plaintiff's self-reported severity of pain. (Id.)

         D. Plaintiff's Initial Appeal and MetLife's Reinstatement of Plaintiff's Claim

          By letter dated October 29, 2013, Plaintiff appealed MetLife's determination, submitting additional documentation, including an “Abnormal Neurological Exam Result.” (See D.I. 12 MET/DALY/AR-116-33) Again, a MetLife Nurse Consultant conducted a review, but this time concluded that “[t]he additional clinical documentation supports a severity of impairment that would preclude a RTW [return to work] in any occupation at this time.” (Id. MET/DALY/AR-16) The additional information included records from the neurosurgeon, Dr. Rastogi, and “EMG results and office notes from PCP [primary care physician, Dr. Singson].” (Id.) The Nurse Consultant noted that “[t]he physical exam findings, narcotic medications, MRI and electrodiagnostic findings support low back pain with radiculopathy that would preclude any prolonged sit, stand or walk [sic] which would preclude any work capacity at this time.” (Id.) The MetLife Nurse Consultant further noted that the “[n]eurosurgeon stated that surgical intervention is possible, however [Plaintiff] did not want to proceed with surgery at this time.” (Id.) Accordingly, MetLife “determined that you do meet the requirements set forth in your Plan” and reinstated Plaintiff's claim for benefits. (D.I. 1-2 at 1)

         Subsequently, MetLife sought and Plaintiff continued to provide medical records. (See e.g., D.I. 12 MET/DALY/AR-139-50, 151-63)

         E. MetLife's Second Denial

         In a letter dated May 9, 2016, MetLife again terminated Plaintiff's claim, having “determined that [Plaintiff] no longer me[t] the definition of disability as defined in [Plaintiff's] Plan.” (D.I. 1-3 at 1) As further explanation, the letter noted:

After careful review of information on file it has been determined that the information is insufficient to support a current functional impairment precluding your ability to return to the workforce. Our records show that your last day worked was March 5, 2013 and you were out of work due to cervical low back pain. The most recent medical documentation received appears to show minimal findings. There is no evidence that back surgery or any other treatment other than Epidural steroid injections and physical therapy in 2013. Since that time, there is no evidence of conservative treatment. There have been no changes in pain medications. We have no records from the podiatrist treating the ulcer on your foot.


         F. Plaintiff's Second Appeal

         In a letter dated May 19, 2016, Plaintiff appealed to MetLife, seeking to reinstate his benefits. (D.I. 1-4) Plaintiff provided supporting records, including a 2013 follow-up office visit to his neurosurgeon, Dr. Rastogi (D.I. 12 MET/DALY/AR-315-16), a 2013 MRI result of lumbar spine (id. MET/DALY/AR-317-18), 2013 electrodiagnostic results (id. MET/DALY/AR-319-22), and a Medical Source Statement Dr. Singson had provided to the Social Security Administration, which stated that Plaintiff could stand and/or walk for less than two hours and sit for less than six hours in an eight-hour work day, and could never climb, kneel, crouch or stoop, but could occasionally balance or crawl (id. MET/DALY/AR-323-26). Arguing that his “claim has been improperly terminated, ” Plaintiff contended: “[s]ince the original appeal, the [Plaintiff's] condition has not materially improved;” the denial letter seems to “coerce” Plaintiff into surgical intervention to avoid termination of his benefits; his then-current pain medication was intended to maintain “a delicate balance” between obtaining relief and avoiding addiction; and his Social Security hearing was scheduled for July 16, 2016. (D.I. 1-4 at 1-2)

         G. MetLife's Final Termination of Plaintiff's Claim

          MetLife continued to request updated medical records to “further evaluate [Plaintiff's] claim for ongoing benefits.” (D.I. 12 MET/DALY/AR-166 (October 7, 2015, letter requesting medical records); see also Id. MET/DALY/AR-168 (March 16, 2016 letter requesting same)) In response, Plaintiff provided medical records dated 2013 and neurosurgeon Dr. Rastogi's office visit ...

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