United States District Court, N.D. Illinois, Eastern Division
April 8, 2005.
KATHLEEN WHITE, Plaintiff,
AIRLINE PILOTS ASSOCIATION, INTERNATIONAL and METROPOLITAN LIFE INSURANCE COMPANY, Defendants.
The opinion of the court was delivered by: MORTON DENLOW, Magistrate Judge
MEMORANDUM OPINION AND ORDER
Plaintiff Kathleen White ("Plaintiff" or "White") seeks
judicial review of a final decision denying her Long Term
Disability ("LTD") benefits pursuant to the terms of an Employee
Welfare Plan ("the Plan") sponsored by her former employer,
defendant Airline Pilots Association International ("ALPA"). The
Plan was insured by the defendant Metropolitan Life Insurance
Company ("MetLife"). The issue before this Court is whether
MetLife was arbitrary and capricious in denying White's claims
for LTD benefits.
This case comes before the Court by means of a trial on the
papers in which the parties have submitted briefs and supporting
exhibits which constitute the record in this case. See Sullivan
v. Bornemann, 384 F.3d 372, 375 (7th Cir. 2004) (noting that a
district court decision, rendered after reviewing the stipulated
facts of the parties, was more akin to a bench trial than summary
judgment, and was thus governed by Federal Rule of Civil Procedure 52(a)); Hess v. Hartford Life & Accident Ins. Co.,
274 F.3d 456, 461 (7th Cir. 2001) (entering a judgment based upon
a stipulation of facts that made up an administrative record was
treated as a bench trial governed by Fed.R.Civ.P. 52(a)); La
Barge v. Life Ins. Co. of N. Am., 2001 WL 109527, *1
(N.D.Ill.Feb. 6, 2001) (conducting a trial on the papers in an
ERISA case); Morton Denlow, Trial on the Papers: An Alternative
to Cross-Motions for Summary Judgment, Fed. Lawyer, Aug. 1999,
at 30. The parties agreed to proceed in this manner and to waive
their right to present oral testimony. Oral argument was held on
March 28, 2005.
The following constitute the Court's findings of fact and
conclusions of law pursuant to Rule 52(a) of the Federal Rules of
Civil Procedure. To the extent certain findings may be deemed to
be conclusions of law, they shall also be considered conclusions
of law. Similarly, to the extent matters contained in the
conclusions of law may be deemed findings of fact, they shall be
considered findings of fact.
I. FINDINGS OF FACT
A. THE PLAINTIFF: KATHLEEN WHITE
White was employed by ALPA for fifteen years, from January,
1987 to May, 2002. R. 74. Her position with ALPA was "Senior
Communications Specialist," R. 26, where she provided support and
counsel to ALPA's Director of Communication and to the Master
Executive Counsel for the United Air Lines Pilots regarding
member relations, media relations, public relations, editorial services, and video
production. White Aff. ¶ 7, Exh. A.*fn1 White has two
Bachelor of Arts Degrees, one in Journalism and Marketing from
Lewis University and a second in Labor Studies from Antioch
College, as well as a Master's Degree in Business Administration,
also from Lewis University. White Aff. ¶ 3.
B. PROCEDURAL HISTORY
As an insurance benefit of her employment, White was insured
under a long term disability insurance policy underwritten by
MetLife. R. 47-73. On May 17, 2002, White stopped working at
ALPA. R. 28. White claimed that she was disabled and unable to
return to work as a result of physical pain and mental depression
resulting from a thoracotomy*fn2 on her right lung, an
incurable blood disease called porphyria cutanae tardia
("PCT"),*fn3 mitral valve prolapse,*fn4 and carotid arteriosclerosis.*fn5
White filed her application with MetLife for LTD benefits on
September 10, 2002 through ALPA's Benefits/HRIS Administrator,
Matthew Szlapak. R. 25-45. MetLife denied her application on
November 1, 2002. R. 210-12. White appealed the decision on
November 22, 2002. R. 17-18. Included in her appeal was a letter
dated November 8, 2002, prepared by her treating physician, Dr.
Adam Milik, in which he opined that White was unable to return to
work. R. 19-20. This appeal was denied on December 12, 2002. R.
214-17. Plaintiff sent MetLife more documents in support of her
appeal on January 30, 2003, March 20, 2003, and on April 10,
2003. R. 119-22, 204, 224. MetLife again denied her claim. R.
White brought this lawsuit on May 10, 2004. This case is before
the Court on a trial on the papers. The record before the Court
consists of the MetLife administrative record compiled by MetLife
in reviewing White's claim. R. 1-237.*fn6 On December 19,
2003, the Social Security Administration approved White's claim
for disability insurance benefits, R. 193-95, commencing in January, 2004. R. 195.
C. THE METLIFE DISABILITY PLAN
The MetLife Disability Policy ("the Plan") provides long term
disability benefits to otherwise eligible Plan participants
deemed "totally disabled". R. 68. The Plan covers "all active
full time senior managers and directors." R. 72. It provides that
a participant must first be continuously disabled for a 90 day
"Elimination Period" before he or she may become eligible for
benefits. R. 68. The Plan defines "disability" as:
"Disable" 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; and
1. during your Elimination Period and the next 36
month period, you are unable to earn more that 80% of
your Predisability Earnings or Indexed Predisability
Earnings at your Own Occupation for any employer in
your Local Economy; or
2. after the 36 month period, you are unable to earn
more than 60% of your Indexed Predisability Earnings
from any employer in your Local Economy and any
gainful occupation taking into account your training,
experience and Predisability Earnings.
MetLife reviewed Plaintiff's claim during the "Own Occupation"
phase. The Plan defines "Own Occupation" as:
"Own Occupation" means the activity that you
regularly perform and that serves as your source of
income. It is not limited to the specific position
that you held with your Employer. It may be a similar
activity that could be performed with your Employer
or with any other Employer.
R. 67. The Plan also provides the following definition of the term
"Local Economy" means the geographic area surrounding
your place of residence which offers reasonable
employment opportunities. It is an area within which
it would not be unreasonable for you to travel to
secure employment. If you move from the place you
resided on the date you became Disabled, we may look
at both the former place of residence and your
current place of residence to determine the local
The Plan vests MetLife, as Plan fiduciary, with discretionary
authority to make determinations of eligibility for LTD benefits.
In carrying out their respective responsibilities
under the Plan, the Plan administrator and other Plan
fiduciaries shall have discretionary authority to
interpret the terms of the Plan and to determine
eligibility for entitlement to Plan benefits in
accordance with the terms of the Plan. Any
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
D. WHITE'S MEDICAL CONDITION AND TREATMENT RECORDS
1. Dr. Adam W. Milik Primary Treating Physician Before
On May 15, 2002, White began experiencing a severe pain in her
right side. R. 120, 123. After the pain did not subside within a
few days, White consulted her primary care physician, Dr. Adam
Milik. R. 120, 123. Dr. Milik thought that White may be suffering
from a gallbladder problem, but testing of her liver,
gallbladder, and pancreas revealed nothing. R. 123, 39. 2. Dr. Raju Z. Abraham Emergency Room Doctor
On May 24, 2002, when the pain persisted, White presented
herself to the emergency room at Riverside Medical Center where
she was seen by Dr. Raju Abraham. R. 123. Dr. Abraham prepared a
"History of Present Illness" which noted that an x-ray had
revealed an increasing right effusion*fn7 and infiltration
in her chest. R. 123-26. Dr. Abraham noted that White had
increased pain in her right lower chest, shortness of breath, and
shallow respirations. R. 123. Dr. Abraham also noted that White
had a history of medical problems including PCT, mitral valve
prolapse, and carotid arteriosclerosis. R. 123-25.
3. Dr. Paul E. Rowland Surgeon
White was eventually diagnosed with "right lower lobe pneumonia
with multiloculated pleural effusions and entrapped right lower
and middle lobes of the lung." R. 129. On May 29, 2002, White
underwent a thoracotomy*fn8 on her right lung which was
performed by Dr. Paul Rowland. R. 127-32. Following the surgery,
White remained under the care of Dr. Roland until July 16, 2002.
R. 21. On July 16, 2002, Dr. Rowland wrote to Dr. Milik, updating
him on the condition of his patient and noting that White's
"wounds have healed normally and she is doing well. The chest
wall discomfort is improving fairly rapidly." R. 21. 4. Dr. Adam W. Milik Primary Treating Physician After
On August 5, 2002, White returned to Dr. Milik complaining of
"atypical" right sided chest pains and shortness of breath. R.
23. Dr. Milik noted that the pains were on and off, sometimes
lasting the entire day. Id. Dr. Milik noted that White was very
emotional and cried easily. White's EKG was normal; there were no
signs of ischemia, and she had a normal sinus rhythm. Id. Dr.
Milik reported that White "does not really want to go back to her
previous job." Id. He diagnosed her with major depression, gave
her a prescription for Paxil and pain medication, and ordered a
chest x-ray to rule out pleural effusion. Id.
Dr. Milik saw White again on August 27, 2002. R. 22. Although
she denied chills, fever, nausea or vomiting, Dr. Milik observed
that there was no difference in White's right chest wall pain and
she still experienced occasional shortness of breath. Id. The
chest area pain was somewhat improved with physical therapy, but
there had been no response to the pain medication, so he stopped
her prescription. Instead, Dr. Milik prescribed Mobic and
Neurontin because he suspected a "neuropathic component" to her
pain. Id. As far as White's mental stability, Dr. Milik noted
that her depression seemed to be improving with the Paxil, so he
continued her prescription. He also thought that White's
continued shortness of breath was "secondary very likely to major
Dr. Milik saw White again on September 9, 2002. R. 24. His
notes reflect that White still suffered from right sided chest
pain and that it was "getting worse." Id. He also noted that
she continued to have shortness of breath. Dr. Milik gave White a
referral to a pain clinic. Her major depression was "very well controlled" and Dr.
Milik concluded that White should continue taking the Paxil. R.
24. Dr. Milik's opinions regarding White's ability to return to
work are discussed infra, in connection with MetLife's
processing of White's claim. See Parts I.E.1-3.
5. Dr. Robert A. Menotti Independent Physician Consultant
During the review process, MetLife forwarded Plaintiff's
medical records to Dr. Robert A. Menotti, an independent
physician consultant ("IPC"), for a "Physician Consultant
Review". R. 208-09. Dr. Menotti gave his opinion of Plaintiff's
ability to return to work by summarizing what he found to be
important in Drs. Rowland's and Dr. Milik's records. R. 208.
First, Dr. Menotti noted that Dr. Rowland's records indicated
that Plaintiff was healing normally after her surgery and that
her chest discomfort was improving fairly rapidly. Id. Next,
Dr. Menotti discussed Dr. Milik's conclusions that Plaintiff had
not yet returned to her presurgical condition, citing shortness
of breath and major depression. Id. Dr. Menotti noted that Dr.
Milik's records indicated that Plaintiff also suffered from a
skin condition, had some narrowing of her left internal carotid
artery, and suffered from mitral valve prolapse. Id.
Dr. Menotti summarized, "the claimant had an acute episode of
pneumonia that was complicated by pleural effusion and later
entrapment of the right lung . . . [but] there were no
complications of a serious nature one normally sees as a result
of this. . . ." Id. Dr. Menotti concluded:
There is simply not enough medical documentation from
Dr. Milik to lead this reviewer to believe at this
point in time that the claimant is not medically able to return to the essential duties of her own
occupation following her acute lung surgery. I would
expect there to be more medical to flow into this
chart regarding the management of the other chronic
conditions. However, the documentation at this point
in time relating to these chronic conditions does not
appear to be enough to preclude her from performing
the essential duties of her own occupation at this
point in time.
R. 209 (emphasis added).
6. Toni Blumenthal White's Therapist
On March 5, 2003, White met with a therapist at Riverside
Behavioral Services, Toni Blumenthal. R. 229-237. Blumenthal's
report indicates that White had a functional impairment
associated with her symptoms of depression, in the areas of "self
care and maintenance" and "role functions in job or home/daily
living skills." R. 230. Blumenthal indicated that he did not
believe White could work as it was difficult to do any daily
jobs. Id. He noted that White appeared "very hyper, almost
hypermanic," and that her speech was rapid. R. 235.
7. Dr. Reginald A. Givens Independent Physician Consultant
In April 25, 2003, MetLife sent White's file to another IPC,
Dr. Reginald A. Givens, a Board Certified psychiatrist. R. 206.
Dr. Givens did not examine White nor is there any indication that
he spoke to White's treaters. The record is unclear as to what
MetLife sent to Dr. Givens, but on May, 6, 2003, Dr. Givens sent
MetLife a recommendation letter, at the top of which he listed
White's job as "customer service assistant." R. 218-20. Dr.
Givens diagnosed White with depression, and noted that the
"general progression of symptoms has been toward improvement." R.
218. He stated, "Ms. White's level of functionality based upon objective evidence in the medical records are that she
maintains the ability to understand and memorize, also to sustain
concentration persistence, to engage in social interactions
either occupationally or in the general public." R. 219. "[U]nder
the assumption that the records presented for review and
consideration are true and correct," Dr. Givens concluded, "the
medical records demonstrate that there are no psychiatric
functional limitations that would have precluded her from
performing all of her occupation from 05/17/02 to the present."
E. METLIFE'S LONG TERN DISABILITY BENEFITS DETERMINATION
1. White's Disability Application
White's 90-day Elimination Period, during which she was
required to be continuously disabled as defined under the terms
of the Plan in order to become eligible for benefits, ended on
August 15, 2002. R. 68, 215. White filed her application for
ALPA's LTD benefits on September 10, 2002 through ALPA's
Benefits/HRIS Administrator, Matthew Szlapak. R. 25-45. The
application was a MetLife LTD Disability Claim form in three
parts: an Employee Statement, R. 26-27, an Employer Statement, R.
28-29, and the Attending Physician Statement, R. 30-31.
In the first part of the application, the Employee Statement,
White identified Dr. Milik as her primary care physician and Drs.
Milik, Gombiner, and Rowland as physicians she had seen in the
previous two years. R. 26. She stated that Dr. Milik had been
treating her for mitral valve prolapse since January 2001, that
Dr. Gombiner had been treating her for PCT since November 2000, and that Dr. Rowland had been her surgeon
for the thoracotomy in May 2002. R. 26. She also signed an
authorization for the release of her medical records. R. 27. In
response to the question "[p]lease describe what prevents you
from preforming the duties of your job", White responded,
"physically and mentally unable. See Dr.'s notes." R. 26.
In the second part of the application, the Employer Statement,
Mr. Matthew Szalpak, ALPA's Benefits Manager, identified White's
job as "Communications Specialist." R. 28. On the pre-printed
form, Szalpak identified the physical and mental requirements of
a Communications Specialist by checking boxes. R. 29. For
instance, Szalpak estimated that White was required to sit for
5-6 hours a day while she only stood for 1-2 hours every day.
Id. In response to MetLife's inquiry as to the "frequency of
interpersonal relationships necessary to perform the job",
Szalpak placed White's job at the higher end of the
"continuously" category. R. 29, Item No. 18. Also, in quantifying
the "frequency of stressful situations necessary to perform the
job", Szalpak placed White's job between "frequently" and
"continuously." R. 29, Item No. 19.
Although the form required that ALPA "must also attach a copy
of your company's job description for the employee," no such
description was attached to White's application, and no such job
description was contained anywhere in the file.*fn9 R. 29. In the third part of the application, the Attending Physician
Statement, Dr. Milik stated that White's primary diagnosis and
treatment was "pneumonia with effusion", her secondary diagnosis
and treatment was PCT, and her symptoms were chest pains and
shortness of breath. R. 29-30. Dr. Milik also listed the
medications that White was taking, including Paxil. R. 30. Dr.
Milik checked the box on the MetLife form to indicate that White
was "unable to engage in stressful situations or engage in a
personal relationship (marked limitations)." R. 30. Dr. Milik
also attached a number of laboratory and other reports relating
to White's medical condition in May of 2002 and the surgery
performed on her at that time. R. 32-45.
2. MetLife's Initial Denial of White's Disability Claim.
On September 18, 2002, White's claim was assigned to a MetLife
employee, identified only as "N 235" for review. R. 3. On October
1, 2002, a nurse consultant ("NC") did a "walk-up" with the case
management specialist regarding White's claim. R.3. The record
indicates only that the NC reviewed the lab reports and Dr.
Milik's Attending Physician statement. At that time, the NC was
"not sure" what the diagnosis was. R. 4. The record also
indicates that the NC asked Dr. Milik's office to send White's
medical records, and Dr. Milik's medical notes were included in
the record a short time thereafter. R. 4
On October 16, 2002, the NC issued an internal "initial review
recommendation" regarding White's case. R. 4. First, the NC
incorrectly identified White's job at ALPA as a "customer service
assistant" and then concluded that this position "most likely
[fell within] the lt [light] work category." Id. The NC briefly summarized
White's medical troubles and then concluded that "the medicals do
not support restrictions and limitations which would preclude
[White] from her light work." Id. That same day, N 235 entered
a "denial summary" into MetLife's file. R. 5. In the denial
summary, N 235 correctly identified White's job as a
"Communications Specialist," gave a brief synopsis of her major
symptoms, and concluded by recommending a denial because the
"medical records do not support" a disability. Id.
By letter dated November 1, 2002, MetLife notified White that
it had denied her claim for LTD benefits. R. 210-12. The letter
correctly stated White's job title and then stated simply that
the records provided by Dr. Milik "do not support impairments
that would prevent you from returning to your light level
position." R. 211. The letter gives a brief summary of White's
medical conditions, but did not mention her diagnosis of major
depression, her prescriptions for any drugs besides the first
pain medication prescribed by Dr. Milik, the recommendation that
White attend a pain management program, or Dr. Milik's conclusion
that White's job had "marked limitations" in her ability to
engage in stressful situations or interpersonal relationships. R.
3. MetLife's Denial of White's First Appeal
On November 22, 2002, ALPA's Benefits/HRIS Administrator,
Matthew Szlapak, faxed to MetLife White's appeal from the denial
of her disability claim. R. 17-24. Included in White's appeal was
a letter dated November 8, 2002 prepared by Dr. Milik. R. 19-20.
Dr. Milik explained that he was writing at White's request to provide
a "concise, specific narrative written report as to her current
medical condition, how it happened and why based on this
condition she can no longer work." R. 19. In the letter, Dr.
Milik opined that: 1) White continued to complain of upper right
flank pain despite multiple changes to medications and recently
completed physical therapy; 2) he had recommended that White see
a chronic pain specialist; 3) White continued to experience
shortness of breath and had developed major depression; 4) White
also suffered from other chronic conditions such as PCT,
narrowing of the carotid artery, and mitral valve prolapse; and
5) he had learned from White that her job involved a lot of
stress and required a lot of travel, meetings, and carrying heavy
objects such as a computer, cameras, and briefcases. Id. Dr.
Milik stated, "obviously with her current medical condition and
continuing pain as well as major depression, she would not be
able to continue at her previous position." Id. He concluded
that White's condition was "chronic" and would require a
prolonged period of time to improve. Id. He closed by stating,
"from what the patient is telling me about her position, it
appears that she would not be able to return to her work at the
present time." R. 20.
MetLife received White's appeal on November 21, 2002. R. 16.
The record contains a copy of an "Appeal Referral Form", R.
11-12, which indicates that a nurse had initially reviewed
White's claim and that MetLife's records still did not contain a
job description. R. 11.
On December 9, 2002, MetLife sent White's file to an IPC, Dr.
Robert A. Menotti. On MetLife's IPC referral form, MetLife incorrectly stated twice
that White's job title was "Customer Service Assistant". R.
14-15. MetLife characterized White's primary diagnosis as
"shortness of breath". R. 14. The form also directed Dr. Menotti
not to call White's attending physician, Dr. Milik. Id.
By letter that same day, Dr. Menotti recommended that MetLife
deny White's claim for disability. R. 208-09. This letter,
discussed supra,*fn10 does not address the fact that White
continued to experience pain in her side after the surgery, nor
does it mention that White had been referred to a chronic pain
clinic; the letter also does not address the nature (or even
identify the title) of White's job. Id. Dr. Menotti's letter
merely concluded that "at this point in time" there was nothing
to indicate that White was not medically able to return to "the
essential duties of her own occupation." R. 209. Dr. Menotti did
not examine White and he did not contact Dr. Milik.
Three days later, on December 12, 2002, MetLife notified White
that her appeal from the denial of LTD had been rejected. R.
214-17. The letter correctly referred to White's job title as
"communications specialist" and then stated, "we received no
documentation or medical rational to support your inability to
perform your own occupation." R. 216. The MetLife letter also
stated that during the review of White's appeal, White's file had
been reviewed by an IPC who concluded that "there is not enough
medical documentation from Dr. Malik (sic) to support that you
are medically unable to return to your own occupation." Id. MetLife informed White that she had exhausted her
administrative remedies under the Plan and that no further
appeals would be considered. R. 217.
4. MetLife's Rejection of White's "Second" Appeal
On January 30, 2003, ALPA's Matt Szalpak again provided to
MetLife "new materials for consideration as regards White's LTD
claim." R. 119-45. Included in the documents were: 1) a narrative
of White's medical condition from May 15, 2002, forward, R.
120-22; 2) Riverside Medical Center records relating to White's
thoracotomy, R. 123-32; 3) reports prepared by a chronic pain
consultant, Dr. Sundershand Saxena, of the Center for Pain
Treatment, R. 133-37; 4) pre-May 2002 medical and diagnostic
reports relating to White's mitral valve prolapse heart
condition, R. 138-142; 5) a copy of Dr. Milik's November 8, 2002
letter, R. 143-44; 6) photographs of White's hands showing
manifestations of PCT, R. 145; 7) a summary description of PTC,
R. 90; 8) correspondence between White's dermatologist, Dr.
Gombiner, and Dr. Milik regarding the treatment of PCT, R. 91-92;
9) a report to Dr. Gombiner from Dr. Jean Baptiste and Dr. Brieva
of the Northwestern Medical School Department of Dermatology
dated December 17, 2001, relating to White's PTC, R. 93; and 10)
an ambulance report and treatment notes relating to a syncopal
episode experienced by White in 2001, R. 94.
These additional records were not forwarded to Dr. Menotti.
They were reviewed by a MetLife nurse. On February 11, 2003, an
employee at MetLife sent Matt Szalpak an e-mail that stated: The nurse has completed a review of the file. There
is no new medical except for the photographs, which
would overturn the initial decision to deny the claim
or the initial decision to deny the claim or the
Appeal Unit's decision to uphold denial.
R. 118. White was also sent a letter from MetLife notifying her
of MetLife's decision. The letter, dated March 4, 2003, stated
that the documents sent by Szalpak on January 30, 2003, "do not
support the restrictions of disability." R. 213. Again, MetLife
stated that the denial constituted MetLife's final determination.
5. MetLife's Denial of White's Third Appeal
Sometime in late March or early April, ALPA sent to MetLife a
re-application for LTD benefits on behalf of White. R. 224-25.
The record only includes a portion of this re-application,
including a letter from Matthew Szalpak dated March 20, 2003, R.
224, and an employee statement signed by White on March 19, 2003.
R. 225. On May 8, 2003, ALPA and White both received letters from
MetLife informing them that a separate LTD claim filed on White's
behalf on or about April 10, 2003 had been rejected. R. 203,
204-07. Unfortunately, the record of MetLife's consideration of
White's LTD claim contained no other documents relating to the
April 2003 LTD claim until MetLife attached them as an appendix
to its response brief. R. 218-37. The new portion of the record
shows that during May, 2003, MetLife received additional records
from a pain specialist as well as a mental health specialist,
MetLife claims to have sent White's new documentation to
another IPC, Dr. Reginald A. Givens, a Board Certified
psychiatrist. R. 206, 218-20. Dr. Givens sent MetLife a letter on May 6, 2003, in which he concludes, "from a psychiatric
perspective, the medical records demonstrate that there are no
psychiatric functional limitations that would have precluded her
from performing all of her occupation from 5/17/02 to the
present." R. 219.
6. Records Relating to Another MetLife Claimant
Disturbingly, the record also contains numerous documents
relating to another claimant. R. 147-71. MetLife offered no
explanation for these apparently stray documents.
7. MetLife Fails to Respond to Social Security's Finding of
In December of 2003, the Social Security Administration made a
determination that White was totally disabled and entitled to
disability payments. R. 193-95. In January 2004, White's attorney
notified MetLife that White had qualified for Social Security
Disability Insurance, and requested that her claims to LTD
benefits under the Plan be reviewed. R. 191-92. The record does
not contain any response from MetLife.
II. CONCLUSIONS OF LAW
This suit comes before this Court pursuant to the Employee
Retirement Income Security Act of 1974 ("ERISA"),
29 U.S.C. § 1001, et seq. Jurisdiction lies in this Court pursuant to
29 U.S.C. § 1132(a)(1)(B). Exbom v. Cent. States, Southeast &
Southwest Areas Health & Welfare Fund, 900 F.2d 1138, 1140-41
(7th Cir. 1990). Venue is properly placed in the Northern
District of Illinois pursuant to 29 U.S.C. § 1132(e)(2) and
28 U.S.C. § 1391. B. LEGAL STANDARDS
Congress enacted ERISA "`to promote the interests of employees
and their beneficiaries in employee benefit plans, and to protect
contractually defined benefits.'" The Black & Decker Disability
Plan v. Nord, 538 U.S. 822, 830 (2003) (quoting Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 113 (1989)). "ERISA and the
Secretary of Labor's regulations under the Act require a `full
and fair' assessment of claims and clear communication to the
claimant of the `specific reasons' for benefit denial." Id. at
1967; see also 29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1.
1. Standard of Review is "Arbitrary and Capricious"
Under ERISA, the judicial standard of review for benefit
determinations hinges on whether the plan administrator or
fiduciary has been granted discretion in making the benefit
determination. Firestone, 489 U.S. at 115; Ruiz v. Cont'l Cas.
Co., 400 F.3d 986, 989 (7th Cir. 2005). As a default, courts
review benefit determinations under ERISA through the application
of a de novo standard. Firestone, 489 U.S. at 115; Ruiz,
400 F.3d at 989. However, if the administrator or fiduciary is
given discretionary authority to determine eligibility for
benefits, the decision will be reviewed under the deferential
arbitrary and capricious standard. Ruiz, 400 F.3d at 989. Under
the arbitrary and capricious standard, a fiduciary's decision to
deny a claimant benefits is entitled to great deference. Id. at
991. The fiduciary's decision will not be overturned unless the
decision is "downright unreasonable." Id.; see also Herzberger
v. Standard Ins. Co., 205 F.3d 327, 329 (7th Cir. 2000) (stating
that determinations will be overturned by the court only when they are
"unreasonable, and not [when] merely incorrect."); Trombetta v.
Cragin Federal Bank for Sav. Employee Stock Ownership Plan,
102 F.3d 1435, 1438 (7th Cir. 1996) (finding that the administrator's
decision is arbitrary or capricious "only when the decisionmaker
has relied on factors which Congress has not intended it to
consider, entirely failed to consider an important aspect of the
problem, offered an explanation for its decision that runs
counter to the evidence . ., or is so implausible that it could
not be ascribed to a difference in view or the product of . . .
expertise.") (internal quotations omitted).
Relevant factors to be considered include "the impartiality of
the decisionmaking body, the complexity of the issues, the
process afforded the parties, the extent to which the
decisionmakers utilized the assistance of experts where
necessary, and finally the soundness of the fiduciary's
ratiocination." Chalmers v. Quaker Oats Co., 61 F.3d 1340, 1344
(7th Cir. 1995). A plan administrator's decision will be upheld
where it makes an informed judgment and articulates an
explanation "that is satisfactory in light of the relevant facts,
i.e., one that makes a `rational connection' between the issue
to be decided, the evidence in the case, the text under
consideration, and the conclusion reached." Exbom,
900 F.2d at 1143. However, "[r]eview under the deferential arbitrary and
capricious standard is not a rubber stamp and deference need not
be abject." Hackett v. Xerox Corp. Long-Term Disability Income
Plan, 315 F.3d 771, 774 (7th Cir. 2003). Even under the
deferential standard of arbitrary and capricious, courts will not
uphold an insurer's decision to deny benefits "when there is an absence of reasoning in the record to support it." Hackett,
315 F.3d 771 at 774-75.
The disability insurance policy at issue grants MetLife
"discretionary authority" to determine eligibility for LTD
benefits and to interpret the Plan's terms and conditions. R. 50.
As a result, the Court will review MetLife's denial of White's
benefits under the arbitrary and capricious standard. See
Houston v. Provident Life and Accident Ins. Co., 390 F.3d 990,
995 (7th Cir. 2004) ("When a plan confers such discretion upon
the plan administrator or fiduciary, we shall not disturb a
decision concerning eligibility for benefits unless it is
arbitrary and capricious.").
2. ERISA Statutory Requirements Require a Full and Fair
Because MetLife is both claims administrator and insurer,
MetLife has an inherent conflict of interest. Hightshue v. AIG
Life Ins. Co., 135 F.3d 1144, 1148 (7th Cir. 1998) (citing
Donato v. Metro Life Ins. Co., 19 F.3d 375, 379 n. 3 (7th Cir.
1994)); see Firestone, 489 U.S. at 115 ("Of course, if a
benefit plan gives discretion to an administrator or fiduciary
who is operating under a conflict of interest, that conflict must
be weighed as a facto[r] in determining whether there is an abuse
of discretion.") (internal quotations omitted). When the claim
administrator has such a conflict of interest, "though the
standard of review is nominally the same, the judicial inquiry is
more searching." Ladd v. ITT Corp., 148 F.3d 753, 754 (7th Cir.
1998).*fn11 ERISA requires that an insurance company follow certain minimum
standards for procedures and notification when the insurance
company denies an application for LTD benefits. See
29 U.S.C. § 1133. In general, ERISA and the Secretary of Labor's regulations
under the Act requires that specific reasons for denial be
communicated to the claimant and that the claimant be afforded an
opportunity for `full and fair review' by the administrator."
Nord, 538 U.S. at 825; Halpin v. W.W. Grainger, Inc.,
962 F.2d 685, 688 (7th Cir. 1992); see also Hawkins v. First Union
Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir.
2003) (finding for the claimant despite the deference of the
"arbitrary and capricious" standard because there were mere
"scraps" of evidence offsetting the conclusion that claimant was
disabled); Crespo v. Unum Life Ins. Co. of Am.,
294 F.Supp.2d 980, 994 (N.D. Ill. 2003) (finding that the insurance company's
denial of claimant's claim was arbitrary and capricious because
the review was neither full nor fair).
The core requirements of a full and fair review include
"knowing what evidence the decision-maker relied upon, having an
opportunity to address the accuracy and reliability of that
evidence, and having the decision-maker consider the evidence
presented by both parties prior to reaching and rendering his
decision." Brown v. Retirement Comm. of Briggs & Stratton
Retirement Plan, 797 F.2d 521, 534 (7th Cir. 1986); see also
Weaver v. Phoenix Home Life Mut. Ins. Co., 990 F.2d 154, 157
(4th Cir. 1993) ("[A] full and fair review must be construed not only to allow a pension plan's trustees to
operate claims procedures without the formality or limitations of
adversarial proceedings but also to protect a plan participant
from arbitrary or unprincipled decision-making.").
The particular provision of ERISA sets out the following duties
for plan administrators:
(1) provide adequate notice in writing to any
participant or beneficiary whose claim for benefits
under the plan has been denied, setting forth the
specific reasons for such denial, written in a manner
calculated to be understood by the participant, and
(2) afford a reasonable opportunity to any
participant whose claim for benefits has been denied
for a full and fair review by the appropriate named
fiduciary of the decision denying the claim.
29 U.S.C. § 1133 (emphasis added); see also Halpin,
962 F.2d at 689. Further, several regulations also provide the following in
relation to the contents of the notice of claim denial:
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions
on which the denial is based;
(3) A description of any additional material or
information necessary for the claimant to perfect the
claim and an explanation of why such material or
information is necessary; and
(4) Appropriate information as to the steps to be
taken if the participant or beneficiary wishes to
submit his or her claim for review.
29 C.F.R. § 2560.503-1(f).
These requirements ensure that when a claimant appeals a denial
to the plan administrator, he will be able to address the
determinative issues and have a fair chance to present his case."
Halpin, 962 F.2d at 689; see also Gallo v. Amoco Corp,
102 F.3d 922, 922-23 (7th Cir. 1996). "In determining whether a plan
complies with the applicable regulations, substantial compliance is sufficient." Halpin,
962 F.2d at 690. "Every procedural defect will not upset a trustee's
decision." Id. (quoting Wolfe v. J.C. Penney Co.,
710 F.2d 388, 393 (7th Cir. 1983)). "The application of these standards to
a particular disability situation is necessarily a fact-intensive
inquiry." Halpin, 962 F.2d at 690.
C. METLIFE'S DECISION TO DENY LTD BENEFITS TO WHITE WAS
ARBITRARY AND CAPRICIOUS
Under ERISA, the insurer must make a full and fair assessment
of the claims and if it denies disability, it must clearly
communicate to the claimant the specific reasons for the benefit
denials. 29 U.S.C. § 1333. MetLife did not conduct a full and
fair review and therefore its decision to deny White LTD benefits
was arbitrary and capricious. See e.g. Hawkins, 326 F.3d at 919
(holding that the insurer's discretion to review a claim is not
unlimited and indeed cannot be upheld if "the record contains
nothing more than scraps to offset the evidence" presented by the
claimant and her doctor); Quinn v. Blue Cross & Blue Shield
Assn., 161 F.3d 472, 476-77 (7th Cir. 1998) (finding that an
insurer's review was arbitrary and capricious when the insurance
company failed to adequately investigate the requirements of the
claimant's previous occupation).
1. Failure to Accurately Name or Describe White's "Own
The first reason that MetLife did not make a full and fair
review of White's claim is that MetLife failed to accurately name
or describe White's own occupation. Throughout the application
and appeals process, MetLife continually denied White benefits
because White's medical records did not support her inability to
perform her "own occupation". R. 211, 209, 216, 219. However, MetLife never received a description from ALPA
of White's "own occupation, "even though MetLife's own policy
required that such a job description be included in the file.
See R. 29 (MetLife's LTD Disability Claim Form mandates that
the employer, ALPA, provide a written job description of the
employee's position). This Court is unclear how MetLife's
reviewing nurse and the two IPC's (Dr. Menotti and Dr. Givens)
could possibly find that White was medically able to perform the
duties of her "own occupation" when there was no job description
in the file to indicate what her "own occupation" actually
Even more disturbing, on three separate occasions, MetLife
actually misstated White's job title, calling her a "customer
service assistant" rather than a Senior Communications
Specialist. R. 4, 14-15. Indeed, these misstatements came at
critical times in the applications process. In White's initial
application for LTD benefits, the unnamed nurse consultant who
reviewed her file and concluded that she did not qualify for
benefits stated that White was a "customer service assistant" and
then made some broad, unfounded assumptions about the difficulty
of a customer service assistant job. R. 4. The second time that
MetLife incorrectly stated White's job title was also at a
critical time in the reviewing process. In the second instance,
MetLife misstated White's job title, stating that she was a
"customer service assistant," on the MetLife Disability IPC
Referral Form that MetLife sent to Dr. Menotti. R. 14-15. This is
critical because Dr. Menotti twice refers to White's ability to
perform her "own occupation." R. 209. This Court cannot be
certain whether Dr. Menotti thought that White's "own occupation" was "customer service assistant" or
"Senior Communications Specialist", but it is obvious that there
was no job description of either position within the file. Even
if Dr. Menotti had discovered that there was a discrepancy and
had somehow correctly concluded that White's job title was Senior
Communications Specialist, he had no information about what a
Senior Communications Specialist at ALPA was required to do. Dr.
Menotti had no contact with White, her employer, or her doctors.
How he then concluded that White was medically able to perform
her "own occupation" remains a mystery.
The third time that the record reflects an erroneous reference
to "customer service assistant" is in Dr. Given's recommendation
letter to MetLife. R. 218-220. At the very top of Dr. Given's
letter, he noted that White was a "customer service assistant."
As an independent physician consultant, Dr. Givens was tasked
with determining whether White was disabled according to
MetLife's own definition. Indeed, in his letter, Dr. Givens
specifically stated the question posed to him by MetLife: "Do the
medical records provided demonstrated(sic) psychiatric functional
limitations that would have precluded Ms. White from performing
her own occupation from 05/17/02-present?". R. 219. Dr. Givens
concluded that they did not. Id. Again, it is inconceivable to
this Court that based upon his erroneous belief that White was a
customer service assistant, Dr. Givens' determination that White
was able to do her "own occupation", was either full or fair. Dr.
Givens himself provided a caveat to his opinion: he stated that
his independent review was rendered "under the assumption that the records presented for review and
consideration are true and correct." Id. The records given to
Dr. Givens were obviously not true and correct.
Other courts in this Circuit have found that a review process
where the insurance company fails to determine what an
applicant's job duties entailed was not full nor fair. See e.g.,
Quinn v. Blue Cross & Blue Shield Assn., 161 F.3d 472, 476-77
(7th Cir. 1998) (discussed infra); Hillock v. Cont'l Cas.
Co., 2004 WL 434217, *5 (N.D. Ill. March 2, 2004) (finding that
the insurer's assumption that the claimant had the ability to
choose when she sat or stood based upon a job description was
arbitrary and capricious). For example, in Quinn v. Blue Cross
and Blue Shield Association, the Seventh Circuit affirmed a
lower court's determination that an insurance company's review
was arbitrary and capricious when the insurance company failed to
investigate the requirements of the claimant's previous
occupation. Quinn, 161 F.3d at 476. In Quinn, the claimant
was a payroll assistant who applied to Blue Cross and Blue Shield
Association ("Blue Cross") for LTD benefits. Id. In order to
determine whether the claimant was eligible for LTD benefits,
Blue Cross procedures required it to determine whether the
claimant was capable of performing another job with a salary
level similar to that of her current job. Id. Blue Cross
decided that the claimant was able to perform another job, but
admitted that during the review process it did not know what the
claimant's job duties entailed, what her exertional requirements
were, any training and experience she possessed, or any
transferable skills she may have obtained. Id. The court found
that the Blue Cross reviewer "simply based her opinion on her own
notion of what a payroll accounts assistant does." This was not enough.
The court explained:
We agree that [the reviewer] was under no obligation
to undergo a full-blown vocational evaluation of
Quinn's job, but she was under a duty to make a
reasonable inquiry into the types of skills Quinn
possesses and whether those skills may be used at
another job that can pay her the same salary range as
her job with [her former employer]. . . . By not even
performing the slightest inquiry into this matter,
[the reviewer] made her decision arbitrarily and
MetLife sets its own procedures for determining whether a
claimant is eligible for LTD benefits. MetLife's fundamental
inquiry is whether the applicant is competent to do work in his
or her "own occupation." In order to determine this, MetLife
requires the employer to attach the employee's job description
with the application. In this case, MetLife did not follow its
own procedures; it reached conclusions about White's ability to
perform her "own occupation" without ever defining what her
occupation was; and on three separate occasions, it actually
misstated White's job title. A review process based upon such
carelessness and inconsistency cannot be considered either full
or fair. Therefore, MetLife's decision to deny benefits to White
was arbitrary and capricious.
2. MetLife Unfairly Restricted the IPC's Independent Review
and Failed to Supply Him With Further Medical Evidence
The other reason that MetLife did not make a full and fair
review of White's claim is that MetLife restricted Dr. Menotti's
ability to review White's claim and then failed to send him
additional medical evidence that could have assisted him in his
evaluation. After White's initial application was denied, MetLife
referred White's claim to Dr. Menotti on December 9, 2002. MetLife did not instruct the doctor to examine
White and in fact it instructed Dr. Menotti not to call her
treating physician, Dr. Milik. R. 14. That same day, Dr. Menotti
wrote back to MetLife concluding, "there is simply not enough
medical documentation from Dr. Milik to lead this reviewer to
believe at this point in time that the claimant is not medically
able to return to the essential duties of her own occupation." R.
209. He continued, "I would expect there to be more medical to
flow into this chart regarding the management of the other
chronic conditions." Id. "However," the doctor concluded, "the
documentation at this point in time relating to these chronic
conditions does not appear to be enough to preclude her from
performing the essential duties of her own occupation at this
point in time." Id.
The doctor's language appears deliberately ambiguous and vague.
Dr. Menotti based his conclusion on the fact that there was "not
enough medical evidence" to support a finding of disability; the
doctor certainly did not rule out the possibility that more
evidence would support a finding that White was disabled. Yet
because of MetLife's instructions, Dr. Menotti had no way of
obtaining more medical evidence in order to reach a more
conclusive recommendation. MetLife effectively tied Dr. Menotti's
hands by giving him medical documents and then not allowing him
to contact White or her reviewing doctor for further information.
Moreover, when White supplied MetLife with additional documents
on January 30, 2003, MetLife never sent them to Dr. Menotti for
further review, even though he previously indicated that he expected more medical evidence to come into the
file. Instead, MetLife gave these new documents to an
unidentified MetLife nurse consultant, whose medical
qualifications are uncertain, who concluded that the new
documents contained no new pertinent evidence. MetLife failed to
allow Dr. Menotti to conduct a truly "independent" review of
White's claim, by instructing him not to talk with the treating
physician and by failing to let him examine all of the medical
It is true that seeking independent expert advice is evidence
of a thorough investigation. Hightshire, 135 F.3d at 1148
(finding that the insurer did not act arbitrarily and
capriciously, partly because the insurer obtained independent
expert advice); see Anderson v. Operative Plasterers' & Cement
Masons' Int'l Assoc. Local No. 12 Pension & Welfare Plans,
991 F.2d 356, 358 (7th Cir. 1993) (upholding a plan administrator's
decision to deny benefits when the plan administrator's decision
was partially based upon an examination by an independent
physician); see also Nord, 538 U.S. 822, 827 (concluding that
the insurer's reliance upon the opinion of an independent
neurologist who examined the claimant was reasonable, despite the
fact that the claimant's treating physician reached a different
result). However, in order for that expert advice to have any
credible weight, the insurer must "investigate the expert's
background, provide the expert with complete and accurate
information, and determine that reliance on the expert's advice
is reasonably justified under the circumstances." Id. In this
case, MetLife did not provide Dr. Menotti with all of the
information, and based upon the limitations MetLife placed upon
the doctor, it could not have reasonably relied upon his advice.*fn12
Under Seventh Circuit case law, a treating physician's
information is likely superior to the information of a plan's
medical consultant, when the consultant has not examined the
claimant but has only spoken to the treating physician on the
telephone. Hawkins, 326 F.3d at 917.*fn13 In this case,
Dr. Menotti did not even talk with Dr. Milik on the phone he
was instructed not to do so by MetLife. Compare Nord,
538 U.S. 822, 827 (noting that the independent consultant conducted an
exam of the claimant); Anderson, 991 F.2d at 358 (noting that
the independent consultant conducted an examination of the
claimant). MetLife's actions in relying so completely on Dr.
Menotti's "independent recommendation" were arbitrary and
D. REMAND IS UNNECESSARY
This Court further finds that remand is unnecessary because on
the record before MetLife the case is so clear cut that it would be unreasonable
for MetLife to deny the application for benefits on any ground
and because MetLife's conduct was patently unreasonable in
failing to provide a full and fair review. Hess,
274 F.3d at 464; Gallo, 102 F.3d at 923; see also Pritcher v. Health Care
Svc. Corp., 301 F.3d 811, 818 (7th Cir. 2002) (upholding a
district court decision to award liability, not merely remand the
case back to the insurer, when it was clear that the insurer's
original decision was "patently unreasonable"); Weaver,
990 F.2d 154, 159 ("[A] remand for further action is unnecessary here
because the evidence clearly shows that Phoenix Home Life abused
The Seventh Circuit has stated that if an insurer merely fails
to make an adequate finding as to a claimant's disability, a
court should not award retroactive benefits without remanding the
case back to the insurer. Quinn, 161 F.3d at 477. However, such
an award of retroactive benefits is proper "where there is no
evidence in the record to support a termination or denial of
benefits." Id. at 477; DiPietro v. Prudential Ins. Co. of
Am., 2004 WL 626818, *11 (N.D.Ill. 2004). To demonstrate when it
might be proper for a court to award benefits without remand, the
Quinn court cited several cases, including Grossmuller v.
Int'l Union, United Auto., Aerospace & Agric. Implement Workers
of Am., UAW, 715 F.2d 853, 858-59 (3d Cir. 1983), where the
insurer's claims procedure did not provide the claimant with a
full and fair review, and Govindarajan v. FMC Corp.,
932 F.2d 634, 637 (7th Cir. 1991), where the insurer conducted a selective
review of the medical evidence and reached a conclusion that was
unreasonable. Quinn, 161 F.3d at 477; see DiPietro, 2004 WL 626818 at *11.
In this case, MetLife's decision to deny White LTD benefits was
patently unreasonable because it did not provide a full and fair
review; therefore remand is unnecessary.*fn14 See Quinn,
161 F.3d at 477. MetLife conducted a careless and superficial
review of White's claim during which it: 1) did not follow its
own procedure; 2) consistently misstated White's job title during
three critical points of the review; 3) did not describe the
background or qualifications for the internal MetLife reviewers
(the "nurse consultants"); 4) included the wrong applicants
information within White's file; and 5) did not attach parts of
the record until filing its response brief in this case. After a
disorganized and imperfect review, MetLife arbitrarily concluded
that White was able to perform her "own occupation" without
considering what White's occupation required. See Weaver,
990 F.2d at 159 (finding that remand was unnecessary because the
insurer abused its discretion).
Further, MetLife did not give Dr. Menotti, MetLife's
"independent physician consultant", an opportunity to fully
review White's claim; rather, it instructed the IPC not to
contact White or her primary physician. Although Dr. Menotti
concluded that there was not enough medical evidence from White's
treating physician to conclude that she was disabled, MetLife
failed to provide him with additional medical evidence when it
received new medical files from White. The recommendation of
MetLife's other IPC, Dr. Givens, is flawed because the doctor did not examine White or talk to her
treaters and he based his opinion on faulty information provided
to him by MetLife regarding her job title and the lack of a job
description. Because MetLife acted arbitrarily and capriciously,
this Court has no confidence that it would give White a full and
fair review if the Court remanded the case back to MetLife. See
Govindarajan., 932 F.2d at 637 (finding that selective review of
medical evidence and a conclusion based on that selectivity was
arbitrary and capricious and did not warrant remand). In
addition, a remand would penalize White and benefit MetLife.
This case is before the Court on a trial on the papers.
Therefore, this Court is required to make findings of fact as
well as conclusions of law. Sullivan v. Bornemann,
384 F.3d 372, 375 (7th Cir. 2004). Based upon the evidence in the record,
there is ample evidence for this Court to conclude that White was
indeed disabled under the MetLife Plan. According to the Plan:
"Disable" 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; and [that] during your
Elimination Period and the next 36 month period, you
are unable to earn more that 80% of your
Predisability Earnings . . . at your Own Occupation
for any employer in your Local Economy.
Both of the treaters who examined White and inquired about her
job requirements concluded that she was unable to continue on in
her "own occupation." R. 29-30 (Attending Physician Statement
signed by Dr. Milik); 19-20 (letter by Dr. Milik attached to
White's first appeal); 229-37 (therapist Toni Blumenthal's
report). Dr. Milik spoke with White about the requirements of her
job and opined that "obviously with her current medical condition
and continuing pain as well as her major depression, she would not be
able to continue at her previous position." R.20. Toni Blumenthal
indicated that he did not believe White could work as it was
difficult for her to do any daily jobs. R. 230. The Court
discounts the recommendations by MetLife's IPCs, Drs. Menotti and
Givens, primarily because neither of those reviewing doctors
examined White or spoke with her treating physicians, nor did
they have any way of knowing White's true occupation, much less
what it required of her on a daily basis. Nothing in the record
controverts the conclusion that White could not continue to work
at her "own occupation" as a Senior Communications Specialist at
ALPA. This Court concludes that she was therefore disabled under
the Met Life Plan.
Furthermore, the Social Security Administration determined that
White was disabled on December 19, 2003. Because the Social
Security determination was rendered after MetLife's final
decision, it was not considered by the Court in regards to the
merits of White's claim. See Perlman, 195 F.3d at 982 (limiting
deferential judicial review under ERISA to the information
submitted to a plan's administrator). However, although this
Court did not consider the Social Security determination for the
purposes of determining whether MetLife's decision was arbitrary
and capricious, Social Security decisions are still relevant and
instructive. Tegtmeier v. Midwest Operating Eng'rs Pension Trust
Fund, 390 F.3d 1040, 1046-47 (7th Cir. 2004); Donato v. Metro.
Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994). Thus, although
determinations made by the Social Security Administration are not
binding in ERISA actions, see Anderson, 991 F.2d at 358-59 (7th
Cir. 1993) (holding that Social Security determinations of disability are not dispositive of
disability under a pension plan), a determination of disability
under the Social Security Act can be considered when applicable.
See Ladd, 148 F.3d at 755-56 (considering the grant of social
security benefits in an ERISA case as it related to defendant
insurance company's actions).
It is true that the Social Security Administration and MetLife
make their determinations based on different standards the
Social Security Administration determines whether a claimant is
disabled from any occupation, whereas MetLife determines
whether the claimant is disabled from his own occupation. See
20 C.F.R. § 416.920. However, an inability to perform one's own
job is one of the five steps necessary to prove entitlement to
Social Security benefits, see id., thus the award of Social
Security benefits by an impartial Administrative Law Judge is
instructive. Only after the Administrative Law Judge has
concluded that the claimant cannot perform her own occupation
does he consider whether the claimant can perform any
occupation. Id. It is likely more difficult for a claimant to
prove that she is disabled from any occupation than to prove that
she is disabled from her own. Although the social security
determination of disability is not binding on this court, it
corroborates the conclusion that plaintiff was disabled from
performing her regular occupation. See La Barge, 2001 WL 109527
at *8 ("The findings of the Social Security Administration is
compelling evidence of [the claimant's] disability.").
As it is clear to this Court that MetLife acted arbitrarily and
capriciously in denying White's claim for LTD benefits, public
policy warrants that White be immediately awarded her past due benefits under the Plan. Hackett, 315 F.3d at 776
(awarding the reinstatement of benefits because the termination
was arbitrary and capricious); see also Halpin, 962 F.2d at 697
(finding that the reinstatement of benefits was proper where
significant procedural defects occurred in the plan
E. PLAINTIFF IS ENTITLED TO ATTORNEY'S FEES
Under ERISA, "the court in its discretion may allow a
reasonable attorney's fee and costs of action to either party."
29 U.S.C. § 1132(g)(1). In awarding attorney's fees to the
prevailing party, the court asks whether the losing party's
position was substantially justified and taken in good faith.
Wyatt v. Unum Life Ins. Co. of Am., 223 F.3d 543, 547 (7th Cir.
2000). The Court finds that MetLife's position was not
substantially justified and was not taken in good faith as
itemized above. See Parts II.C-D. Therefore, White is entitled
to attorney's fees. See Hess, 274 F.3d at 464. IV. CONCLUSION
For the reasons set forth in this opinion, the Court finds in
favor of Plaintiff, Kathleen White, and against Defendant,
Metropolitan Life Insurance Company, for all back payments due
under the Plan, plus prejudgment interest and attorney's fees and
court costs, once these amounts are computed. MetLife shall
continue making future payments to Plaintiff under the Plan until
such time as it makes an adverse determination consistent with
ERISA of her entitlement to LTD benefits under the Plan. The
Court directs counsel to confer in order to assist the parties
and the Court to reach an agreement as to the amount of past
benefits, prejudgment interest, attorney's fees, and costs to be
awarded consistent with this opinion. The status of the agreement
as to the amount of the judgment shall be reported at 10:00 a.m.
on April 26, 2005, and the parties shall submit a proposed final
judgment order. The parties are encouraged to expedite the
exchange of information regarding attorney's fees and costs under
Local Rule 54.3. A final judgment will be entered once all of the
computations have been agreed to or decided by this Court.