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Majeski v. Metropolitan Life Insurance Co.

March 31, 2009

KIRSTEN MAJESKI, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE CO., DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Maria Valdez

MEMORANDUM OPINION AND ORDER

Plaintiff Kirsten Majeski has sued the Metropolitan Life Insurance Co. ("MetLife") to reinstate disability benefits pursuant to § 502(a)(1)(B) of the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment pursuant to Federal Rule of Civil Procedure ("Rule") 56.*fn1 The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Majeski's motion for summary judgment [Doc. No. 29] is denied, and MetLife's motion for summary judgment [Doc. No. 56] is granted.

FACTS

Unless otherwise stated, the following facts are either undisputed or are deemed admitted due to a party's failure to comply with Local Rule 56.1, which this Court strictly enforces. Majeski's claim involves disability income benefits and seeks to restore her disabled employee status and all corresponding employee benefits, including health insurance, life insurance, and prescription coverage insurance. (Pl.'s LR 56.1(a)(3) ¶ 1.) Majeski's suit is brought pursuant to § 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B). (Id.) Title 29, United States Code § 1132(e)(1) and § 1132(f), grant the District Court jurisdiction over the parties and over the subject matter of this dispute. In addition, the Court has subject matter jurisdiction pursuant to 28 U.S.C. § 1331. (Id. ¶ 2.) Venue is proper in this district pursuant to 29 U.S.C. § 1132(e)(2) and 28 U.S.C. § 1391. (Id. ¶ 3.) The ERISA statute at 29 U.S.C. § 1133 provides a mechanism for pre-suit internal appeals of benefit denials; Majeski exhausted all such appeals before filing this suit. (Id. ¶ 4.)

Majeski is, and was at all times relevant to this proceeding, a resident of Chicago, Illinois, located within the Northern District of Illinois. (Id. ¶ 5.) Her date of birth is December 12, 1947. (Id. ¶ 6.) Majeski was employed as a Nurse Consultant by MetLife until June 16, 2006, when she ceased working due to pain in her arms, hands, and shoulders, including numbness in three fingers of her right hand.*fn2 (Id. ¶ 7.)

At all relevant times, MetLife provided benefits to its eligible employees pursuant to the MetLife Options and Choices Plan ("Plan"), which incorporates by reference, inter alia, the claims procedures and coverage provisions of the Short Term Disability ("STD") Summary Plan Description and the Long Term Disability ("LTD") Summary Plan Description. (Def.'s LR 56.1(b)(3)(B) ¶ 8.) The Plan identifies the Plan Administrator as MetLife. (Def.'s LR 56.1(a)(3) ¶ 2.) The Plan expressly confers discretionary authority upon MetLife as the Plan Administrator.*fn3 (Id. ¶ 3.)

At all relevant times, MetLife's Plan constituted an "employee welfare benefit plan" as defined by 29 U.S.C. § 1002(1), and incident to her employment, Majeski received coverage under the Plan as a "participant" as defined by 29 U.S.C. § 1002(7). (Pl.'s LR 56.1(a)(3) ¶ 9.) The Plan provides that the terms and conditions regarding eligibility for benefits are established in each constituent plan's Summary Plan Description. (Def.'s LR 56.1(a)(3) ¶ 4.) According to the STD Plan's Summary Plan Description ("SPD"), the policy defines "disabled" and "disability" as follows:

"Disabled" or "Disability" means that due to illness or accidental injury: -- You are receiving appropriate care and treatment from a doctor on a continuing basis; and -- You are unable to earn more than 80% of your pre-disability earnings at your own occupation for any employer in your local economy.

Your loss of earnings must be a direct result of your illness or accidental injury. Economic factors such as, but not limited to, recession, job obsolescence, pay cuts and job-sharing will not be considered in determining whether you meet the loss of earnings test. (Pl.'s LR 56.1(a)(3) ¶ 10.)

According to the SPD, benefits are payable under the policy as follows:

Temporary Disability Benefits

Temporary disability benefits begin on the fourth work day of your Disability (or as early as the first workday of Disability if you are hospitalized as an in-patient) provided that: -- Your Disability has been approved; -- Your Disability has been continuous; and -- You are under a doctor's care and are receiving active medical treatment for the disabling condition.

You will receive this benefit for as long as your Disability continues, to a maximum of 26 weeks.

If Your Disability Extends Beyond 26 Weeks

You may be eligible for long-term disability benefits if your Disability is approved and continues beyond 26 weeks. (See the Long Term Disability SPD for further details.) (Pl.'s LR 56.1(a)(3) ¶ 11; see Def.'s LR 56.1(a)(3) ¶ 5-6.)

According to the SPD, under Statement of the Company's Rights, the policy states:

The Plan Administrator has full power and discretion to resolve all issues concerning eligibility, status, entitlement to benefits, and any other interpretations under the MetLife Options Plus program. Such interpretations or rulings will be binding on all parties. (Pl.'s LR 56.1(a)(3) ¶ 12.)

On June 19, 2006, Majeski was treated at River Forest Chiropractic, Inc. by Michael J. Heatwole, D.C. (Id. ¶ 13.) Majeski continued chiropractic treatment on June 22, June 24, and June 26, 2006. (Id. ¶ 14.) On June 27, 2006, on a form requested by MetLife, Dr. Heatwole indicated that Majeski was incapacitated and that it was necessary for her to take leave from work in order to be treated for her impairment. Dr. Heatwole also checked a box indicating that Majeski was unable to perform any kind of work. (Id. ¶ 15.) Dr. Heatwole ordered Majeski to obtain an MRI from Oak Park Open MRI. (Id. ¶ 16.)

On June 21, 2006, Allan Boreland, Disability Case Manager for MetLife, conducted an initial interview with Majeski and recorded his notes. Boreland noted that Majeski reported her symptoms as pain in the arms, hands, and shoulders, continuous numbness in three fingers on her right hand, and narrowing in disc C5-6. Majeski informed Boreland that she had a diagnosis of cervical radiculitis; she was seeing Dr. Heatwole three days a week for physical therapy; she had an appointment with Thomas F. Gleason, M.D., an orthopedic surgeon; and she expected to return to work in four to six weeks. (Def.'s LR 56.1(a)(3) ¶ 8.) Majeski received a letter from Boreland on June 21, 2006, indicating that STD benefits had been approved from June 19, 2006 through July 14, 2006, on the basis that Majeski was unable to work due to her participation in physical therapy three times a week. (Pl.'s LR 56.1(a)(3) ¶ 30; Def.'s LR 56.1(a)(3) ¶¶ 9-10.)

On July 5, 2006, Doris L. Yip, M.D. issued a report of an MRI taken of Majeski's cervical spine. The MRI findings showed that Majeski had mild to moderate degenerative arthritic changes of the cervical spine. Additionally, there was evidence of mild central stenosis [spinal cord narrowing] and moderate right and mild left neuroforaminal narrowing at C5-C6 and mild bilateral neuroforaminal narrowing at C6-C7 with mild to moderate central canal stenosis. (Pl.'s LR 56.1(a)(3) ¶ 17; Def.'s LR 56.1(a)(3) ¶ 11.) Dr. Yip also opined that the vertebral body heights and marrow signal intensities were within normal limits and that the cervical spinal cord caliber and signal were normal. (Def.'s LR 56.1(a)(3) ¶ 12.)

On July 11, 2006, Majeski underwent an electromyography and nerve conductor velocity test ("EMG/NCV"). Dr. Yip reviewed the EMG and opined that there was normal activity in both cervical paraspinal muscles. Dr. Yip further stated that there was normal activity in the biceps, normal activity in both brachioradialis, normal activity in both triceps, normal activity in both extensor digits, normal activity in both first dorsal interrosseous, and normal activity in both opponens pollicis. (Id. ¶ 13.)

On July 6, July 10, July 11, and July 13, 2006, Majeski returned for chiropractic treatment. (Pl.'s LR 56.1(a)(3) ¶ 18.) On July 12, 2006, Majeski underwent a physical therapy evaluation at Illinois Bone and Joint Rehabilitation Services. The assessment of the therapist on examination was that clinical findings were consistent with a diagnosis of cervical radiculopathy. The therapist indicated that continued physical therapy was medically necessary for Majeski. (Id. ¶ 19.)

On July 19, 2006, Majeski was treated by her orthopedic surgeon, Thomas F. Gleason, M.D. Dr. Gleason made a clinical diagnosis of a cervical radicular syndrome [irritation of the nerves in the cervical spine] with cervical spondylosis [degeneration] and findings of "degenerative disc disease C4 through C7 with spur/disc complexes with facet arthropathy and associated bulging, particularly on the right C5-6 which abuts the cord without displacement or change in signal, otherwise unremarkable." (Pl.'s LR 56.1(a)(3) ¶ 20; Def.'s LR 56.1(a)(3) ¶¶ 14-15.) Dr. Gleason also reviewed the July 3 MRI and the July 11 EMG/NCV and opined that the EMG/NCV reported "findings compatible with normal study with no evidence of radicular denervation" and "no areas of neuropathy found." (Def.'s LR 56.1(a)(3) ¶ 14.) Dr. Gleason recommended that Majeski receive an evaluation by Chandra Reddy, M.D., an anesthesiologist, for an epidural steroid injection; that Majeski continue physical therapy and thereafter an at-home exercise program; that she take Celebrex; and if there were no contraindications, that she may occasionally use over-the-counter medication. (Id. ¶ 17.)

On July 20, 2006, MetLife notified Majeski by letter from Wayette Statham-Bell, Disability Case Manager, that extension of STD benefits had been approved from July 15, 2006 through August 4, 2006, in order to allow Majeski time to proceed with ongoing treatment. (Pl.'s LR 56.1(a)(3) ¶ 31; Def.'s LR 56.1(b)(3)(B) ¶ 31.)

On July 21, 2006, Majeski saw Dr. Reddy, an anesthesiologist and Pain Management Fellow at the Holy Family Medical Center. Dr. Reddy noted that Majeski reported having increasing pain from working on the computer, which developed into numbness and tingling sensations in her fingers. The lab data reviewed during the examination included the MRI, which showed degenerative changes of the cervical spine, especially at the C5-6 level, and also some mild degenerative change at the C6-7 level. Dr. Reddy's clinical finding and diagnosis was degenerative disease of the cervical spine with spinal stenosis and radicular symptoms of the upper extremity. (Pl.'s LR 56.1(a)(3) ¶ 21.) Dr. Reddy opined that: "There is no tenderness over the cervical spine. Her range of motion of the cervical spine is normal except at severe extension." Dr. Reddy stated that Majeski's range of motion of her cervical spine was normal except for "some discomfort" noted on extremes of right rotation and extension, and that "[o]ther movements of the neck are not painful. There is no muscle spasm." (Def.'s LR 56.1(a)(3) ¶ 20.) Dr. Reddy stated that Majeski's July 11 EMG was a negative study. (Id. ¶ 22.) On July 21, 2006, Dr. Reddy recommended that Majeski try Medrol Dosepak and suggested that if it did not alleviate her pain, she could consider a cervical epidural steroid injection. (Id. ¶ 23.)

By letter on August 8, 2006, MetLife informed Majeski that it approved her leave taken from June 19, 2006 through August 25, 2006 under the Family and Medical Leave Act. (Id. ¶ 18.) The rationale for that decision was to allow Majeski to undergo an epidural injection for the treatment of her cervical radicular syndrome, which was evidenced by positive findings on the MRI, despite the normal EMG. The case manager determined that it was reasonable to extend benefits to allow for physical therapy completion and the resolution of pain and decreased range of movement and radicular symptoms. (Pl.'s LR 56.1(a)(3) ¶ 32; Def.'s LR 56.1(a)(3) ¶ 19.)

On August 14, 2006, Majeski was again treated by Dr. Gleason. According to a letter written by Dr. Gleason describing the office visit, he noted that the EMG showed no evidence of radicular denervation and no areas of neuropathy. However, Dr. Gleason stated that the July 3 MRI demonstrated degenerative disc disease at the C4 through C7 levels of the cervical spine with spur/disc complexes, and with facet arthropathy and associated bulging, particularly on the right at C5-6. Dr. Gleason's diagnosis was right cervical radicular syndrome with cervical spondylosis and findings as in x-ray and MRI scan as well as EMG/NCV study. (Pl.'s LR 56.1(a)(3) ¶ 22; Def.'s LR 56.1(a)(3) ¶ 24.) In his office visit note, Dr. Gleason recommended that Majeski "[f]ollow through with Dr. Reddy for consideration regarding epidural steroid injection." (Def.'s LR 56.1(a)(3) ¶ 25.) In his note, Dr. Gleason also recommended that Majeski's treatment include a home exercise program and stated that she "will follow-up in a four-week period of time for further evaluation and consideration of further treatment which could include return to work at that time." (Id. ¶ 26.)

On August 22, 2006, Majeski was examined by David Weiss, M.D., a physiatrist at Marionjoy Medical Group West Suburban Rehabilitation and Sports Medicine. (Def.'s LR 56.1(a)(3) ¶ 27; Pl.'s LR 56.1(a)(3) ¶ 24.) In his examination notes, Dr. Weiss stated that Majeski reported that "[s]he has tried a Medrol Dose Pack which has helped quite a bit, and she is seeing an orthopedic surgeon who is recommending a steroid injection for which she now wants a second opinion." (Def.'s LR 56.1(a)(3) ¶ 27.) Dr. Weiss opined that Majeski's extremities were normal, she had normal tone in all four extremities, normal strength of all myotomes tested in all four extremities, normal coordination of all four extremities, and normal reflexes of all four extremities. (Id. ¶ 28.) Dr. Weiss also noted that Majeski reported pain upon palpation (trigger points) in several muscle groups. (Id. ¶ 29.) He stated that the July 3 MRI study showed mild to moderate degenerative changes and that the July 11 EMG ruled out cervical radiculopathy. (Id. ¶¶ 30-31.) Dr. Weiss concluded that Majeski had multifactorial etiologies for her pain, which was a direct result of weakness of her lower scapular stabilizers, decreased flexibility, decreased endurance, and working on the computer. (Id. ¶ 32.) He prescribed a two-week course of Relafen, in conjunction with ice and topical anti-inflammatories. He further recommended that Majeski obtain an Acu-massager, a Thera-cane, a Real-Ease pillow, and a Tempur-Pedic pillow and noted that "she will start physical therapy and a home exercise program to improve her lower scapular stabilizer strength and increase the flexibility of her cervical paraspinal muscles." (Id. ¶ 33.)

On August 25, 2006, Majeski received another physical therapy evaluation, from Emily Garbisch, PT DPT CSCS. The therapist noted the physician's diagnosis of myofascial pain syndrome. The therapist further noted Majeski's reports of pain throughout her neck and arm, which increased with sitting and typing more than five minutes. The therapist reported that Majeski had significant tenderness through the right midscapular region, upper trapezius, and latissimus dorsi. Functional deficits were noted, which included being unable to work and unable to type more than five minutes without an increase in symptoms. An examination showed numbness and tingling in the fingers. The therapist's assessment was that the results of the examination were consistent with the medical diagnoses and that Majeski had decreased cervical range of motion, poor strength of scapula and deep cervical stabilizers, overutilized upper trapezius, poor cervical alignment, poor standing and sitting posture, and significant pain in all diagnosed musculature. (Pl.'s LR 56.1(a)(3) ¶ 23.) The therapist also stated that "Good for return to all previous activities without pain," and that Majeski could be expected to achieve pain free cervical range of motion in four to six weeks. (Def.'s LR 56.1(b)(3)(B) ¶ 23.)

On September 5, 2006, Nurse Lynn Booth of MetLife reviewed portions of Dr. Reddy's July 21, 2006 initial physical examination notes and Dr. Gleason's August 14, 2006 office visit note. (Def.'s LR 56.1(a)(3) ¶ 34; Pl.'s LR 56.1(b)(3)(B) ¶ 34.) She opined that Majeski's symptoms were intermittent, her cervical range of motion was functional, her shoulder range of motion was within normal limits, and her strength was near normal. (Pl.'s LR 56.1(a)(3) ¶ 34; Def.'s LR 56.1(a)(3) ¶ 34.) Nurse Booth concluded that "the objective findings do not support a functional impairment that precludes EE's [employee's] ability to perform the duties of her job." (Pl.'s LR 56.1(a)(3) ¶ 34; Def.'s LR 56.1(a)(3) ¶ 35.) On September 12, 2006, Nurse Booth reviewed Dr. Weiss's August 22, 2006 initial medical examination notes. Nurse Booth stated that Majeski's muscle tone, strength, and range of motion were functional. She opined that the objective medical findings did not support a functional impairment preventing Majeski from performing the functional requirements of her sedentary work as a nurse case manager. (Def.'s LR 56.1(a)(3) ¶ 36.) MetLife's Unit Manager agreed that the objective findings did not support a functional impairment. (Pl.'s LR 56.1(a)(3) ¶ 34.)

On September 14, 2006, Boreland, on behalf of MetLife, sent Majeski a letter informing her that after conducting a complete review of her file, MetLife concluded that her medical information did not support eligibility for STD benefits beyond August 25, 2006. (Def.'s LR 56.1(b)(3)(B) ¶ 33; Def.'s LR 56.1(a)(3) ¶ 37.) The letter acknowledged Majeski's pain complaints but stated "pain is a subjective finding." (Pl.'s LR 56.1(a)(3) ¶ 35.) In that letter, Boreland cited the medical records, stating that the records submitted did not support a functional impairment that prevented her from performing her job. (Def.'s LR 56.1(b)(3)(B) ¶ 35.) The letter informed Majeski of her right to appeal MetLife's decision and requested that she support her appeal with "objective medical information that supports a functional impairment" which precluded her from performing the duties of her job as a nurse consultant. (Def.'s LR 56.1(a)(3) ¶ 37.)

In an October 9, 2006 letter, Ray McComb, the Human Resources Director at MetLife's Mount Prospect, Illinois office, informed Majeski that she may request a personal leave of absence or, alternatively, she may return to work by October 13, 2006. (Id. ΒΆ 38.) The letter informed Majeski that MetLife would discuss workplace accommodations in order to facilitate her return to work. The letter further stated: "If you do not show up to work or we do not hear from you by ...


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