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Wolfe v. Metropolitan Life Insurance Company and Lerner New York, Inc..

United States District Court, S.D. Illinois

March 31, 2014

THERESA A. WOLFE, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY and LERNER NEW YORK, INC., Defendants.

MEMORANDUM AND ORDER

J. PHIL GILBERT, District Judge.

This matter comes before the Court on (1) plaintiff Theresa A. Wolfe's motion for summary judgment (Doc. 22) to which defendants Metropolitan Life Insurance Company ("MetLife") and Lerner New York, Inc. ("Lerner") (collectively "Defendants") have filed a response (Doc. 33); and (2) Defendants' motion for summary judgment (Doc. 24) to which Wolfe has filed a response (Doc. 32). For the following reasons, the Court denies Wolfe's motion for summary judgment and grants Defendants' motion for summary judgment.

1. Background

Wolfe was a sales manager for Lerner and participated in an employee welfare benefit plan ("Plan"). The Plan is funded by a group long term disability insurance policy issued by MetLife to Lerner and confers discretionary authority on MetLife to determine eligibility for benefits.

Disability, for purposes of the Plan

means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis in order to maximize your medical improvement and you are unable to earn more than 80% of your Predisability Earnings from any employer in your Local Economy at any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Predisability Earnings.

Doc. 20-2, p. 9. With respect to claims due to "mental or nervous disorders or diseases" the Plan provided that

Monthly Benefits are limited to 12 months during your lifetime if you are Disabled due to a Mental or Nervous Disorder or Disease, unless the Disability results from: (1) schizophrenia; (2) bipolar disorder; (3) dementia; or (4) organic brain disease. "Mental or Nervous Disorder or Disease" means a medical condition of sufficient severity to meet the diagnostic criteria established in the current Diagnostic and Statistic Manual of Mental Disorders. You must be receiving Appropriate Care and Treatment for your condition by a mental health Doctor.

(Doc. 20-7, p. 73). Once a claim for benefits is approved, the Plan requires insureds to provide "proof of continuing disability."

Wolfe stopped working on December 14, 2005, when she began to experience problems with her knee. She filed a claim for disability benefits and was approved for those benefits on June 17, 2006. The date of disability was designated as December 19, 2005. Thereafter, Wolfe also applied for and received disability benefits from the Social Security Administration ("SSA").

She initially treated with Dr. Kyle Shepperson who diagnosed Wolfe with degenerative joint disease of the left knee and a Baker's cyst. The Administrative Law Judge from the SSA found that Wolfe had the following severe impairments: degenerative joint disease, complex tear of the posterior horn of the medial meniscus, tricompartmental chondromalacia, internal derangement of the left knee, and depressive disorder. At the SSA hearing, Karyn Perry, Ph.D. testified that Wolfe's depressive disorder was severe and would affect her ability to deal with the public.

In 2011, MetLife evaluated Wolfe's disability status and, as part of its review, solicited information from Wolfe's treating physicians. Dr. Robert Farmer, Wolfe's family physician, indicated Wolfe suffered from depression and pain. Under physical capabilities, he indicated Wolfe could sit, stand, and walk intermittently for two hours. He indicated Wolfe could not climb or twist/bend/stoop, but could reach above the shoulder level and operate a motor vehicle. She could lift up to fifty pounds "Occasionally, 1-35%, " and 51 to over one hundred pounds "Never, 0%."

Previously, on the 2007 "Physical Capacity Evaluation Form, Dr. Farmer indicated Wolfe could "occasionally (1-33%)" lift up to twenty pounds from floor to waist, ten to twenty pounds from waist to shoulder, and less than ten pounds above shoulder. He indicated that Wolfe could "occasionally (1-33%)" carry twenty to twenty pounds, push twenty-one to fifty pounds, and pull ten to twenty pounds. Dr. Farmer further indicated Wolfe could "frequently (34-66%)" reach above shoulder level and reach front and side.

Dr. Wassila Amari, Wolfe's rheumatologist, also responded to a request from MetLife in 2011. Dr. Amari indicated Wolfe could "intermittently" sit for eight hours, stand for four hours, and walk for four hours. Dr. Amari indicated Wolfe could climb and twist/bend/stoop "occasionally, 1-33%, up to 2.5 hours;" reach above shoulder level "frequently, 34-88%, 2.5-5.5 hours;" and reach front and side at desk level, make fine finger movements, and make eye/hand movements "continuously, 67-100%, 5.5-8 hours." Dr. Amari indicated Wolfe could "frequently, 34-66%, 2.5-5.5 hours" lift up to twenty pounds, "occasionally, 1-33%, up to 2.5 hours" lift up to fifty pounds, and could "never, 0%" lift over fifty pounds. She indicated Wolfe could "frequently 34-66%, 2.5-5.5 hours, push/pull up to twenty pounds, "occasionally, 1-33%, up to 2.5 hours" push/pull twenty-one to fifty pounds, and "never, 0%" ...


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