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DONATO v. METROPOLITAN LIFE INS. CO.

April 30, 1993

CHRISTINE M. DONATO, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE CO., Defendant.



The opinion of the court was delivered by: MILTON I. SHADUR

 Christine M. Donato ("Donato"), a former Kemper Financial Services ("Kemper") employee who was initially granted and then later denied disability benefits under Kemper's Long Term Disability Benefit Plan ("Plan"), has filed this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, against Metropolitan Life Insurance Company ("MetLife"), which underwrote the Plan and served as its Claims Administrator. In response to Donato's claim for reinstatement of her benefits, MetLife argues not only that its disavowal of any current obligation to pay benefits was proper but also that it is entitled to a partial rebate of the amount that it had previously paid under its policy.

 MetLife has now moved for summary judgment under Fed. R. Civ. P. ("Rule") 56. For the reasons stated in this memorandum opinion and order, its motion is granted.

 Background

 Rule 56 imposes on the movant the burden of establishing the lack of a genuine issue of material fact ( Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986)). For that purpose a "genuine" issue does not exist unless record evidence would permit a reasonable factfinder to adopt the nonmovant's view ( Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986)), and only facts that would prove outcome-determinative under substantive law are "material" ( Pritchard v. Rainfair, Inc., 945 F.2d 185, 191 (7th Cir. 1991)). In both respects this Court is "not required to draw every conceivable inference from the record--only those inferences that are reasonable" in the light most favorable to the nonmovant ( Bank Leumi Le-Israel, B.M v. Lee, 928 F.2d 232, 236 (7th Cir. 1991)).

 Summary judgment motions in disability cases such as this one are often particularly suitable for disposition via summary judgment because of the absence of disputed factual issues. *fn1" Instead the parties typically disagree as to whether those uncontested facts meet the "disability" standard--whether it is a statute (as in Social Security cases) or an employee benefit plan (in ERISA cases such as this one) that sets the standard for the payment of benefits.

 In this case the facts as to Donato's physical problems are not controverted. What is in dispute is the significance of those problems as to the existence or nonexistence of a disability under the Plan. Hence the following factual recital speaks briefly of those physical problems, then turns to the medical evaluations that served as the grist for MetLife's decisional mill.

 Donato began working at Kemper as a legal secretary in March 1987. By the fall of 1990 she had begun to feel generally fatigued and to suffer from headaches. As time went on her condition worsened, and she began to feel unusually sensitive to such common stimuli as smoke, perfume and carpeting. But as she told Dr. Theron Randolph in 1990, a traditional allergist whom she had seen earlier had not diagnosed her as being afflicted by any allergies (D. Ex. E at 2). *fn2"

 In consequence of his evaluation based on consultations beginning in October 1990, Dr. Randolph diagnosed Donato as "suffering from an acute susceptibility to environmental chemical exposures" that rendered her unable to work (Randolph Aff. P 3). Dr. Randolph also concluded that continued exposure to common environmental chemicals would be likely to cause continued worsening of Donato's condition (id. P 5).

 In February 1991 Donato submitted a claim to MetLife for disability benefits, claiming that a severe allergic reaction to environmental chemicals had disabled her since July 17, 1990. As support she relied on diagnoses by Drs. Randolph and George Shambaugh, Jr. *fn3" In April 1991 MetLife approved Donato's claim effective January 17, 1991 (that date was six months after the claimed onset of the disability, as the Plan specified for long-term disability coverage). MetLife then began making payments to her (D. 12(m) PP 8-9).

 In May 1991 MetLife forwarded Donato's medical records to a medical consulting firm, Underwriting Medical Actuarial Consultants, Inc. ("UMAC"), for review. UMAC initiated review of Donato's file by a board-certified internist and a roundtable including other doctors, one of them an allergist-immunologist. UMAC's May 31, 1991 report ("UMAC I," D. Ex. C) derided the makeup of Donato's evidence as "wordy, confusing, and providing little if any accepted medical information" (id. at 1) and explained its rationale (id. at 2-3):

 
* * *
 
The evaluation, tests and diagnoses provided by Drs. Shambaugh and Randolph do not conform to medical standards.

 UMAC I concluded "that no disability exists that would prevent this patient from performing the activities of daily living or her duties as a legal secretary" (id. at 3). *fn4"

 In reliance on UMAC I MetLife terminated Donato's benefits. Its August 9, 1991 letter to Donato explained the bases of that decision and advised her as to how ...


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