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Mirocha v. Metropolitan Life Ins. Co.

United States District Court, N.D. Illinois, Eastern Division

July 18, 2014

JOSEPH MIROCHA, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE CO., Defendant

Page 926

For Joseph Mirocha, Plaintiff: Joseph Patrick Berglund, LEAD ATTORNEY, Berglund & Mastny PC, Oakbrook, IL; Kenneth Michael Mastny, Berglund Armstrong & Mastny, P.C., Oak Brook, IL.

For Metropolitan Life Insurnace Company, Defendant: W. Sebastian von Schleicher, LEAD ATTORNEY, Smith, von Schleicher & Associates, Chicago, IL; Jacqueline J. Herring, Smith von Schleicher & Associates, Chicago, IL.

Page 927

MEMORANDUM OPINION AND ORDER

MATTHEW F. KENNELLY, United States District Judge.

Joseph Mirocha filed suit against Metropolitan Life Insurance Company (MetLife) seeking to recover long-term disability benefits, pursuant to section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1132(a)(1)(B). Mirocha and MetLife have filed cross motions for summary judgment. For the reasons detailed below, the Court grants Mirocha's motion for summary judgment, denies MetLife's motion

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for summary judgment, and remands the case to MetLife as plan administrator for proceedings consistent with the Court's decision.

Background

Between October 2003 and April 8, 2011, Palos Community Hospital (PCH) employed Joseph Mirocha as an electrical supervisor. As a benefit of employment, PCH offered Mirocha and other employees long-term disability (LTD) insurance through the Palos Community Hospital Welfare Benefits Plan (the Plan). This group plan was insured by MetLife, which also administered the LTD insurance and evaluated the merits of submitted claims. The Plan grants MetLife " discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan." Record at MET 00296.

Under the Plan's provisions, if a beneficiary becomes disabled while covered by the Plan, MetLife will pay him monthly payments based on a set formula. A beneficiary is considered disabled if, due to illness or disease, he is receiving treatment by a physician and complying with the requirements of treatment, and is unable to earn more than eighty percent of the his pre-disability earnings in his own occupation during a ninety-day elimination period and the following twenty-four months. See id. at MET 00261. To be entitled to benefits, a claimant must submit documentation and establish that he is disabled within the meaning of the Plan.

Coverage under the Plan ended--making the beneficiary no longer eligible for benefits--on the occurrence of certain specific events. Most significantly for purposes of this case, coverage ends on " the date [the claimant's] employment ends." Id. at MET 00266. But the Plan also provides that " While [the claimant is] Disabled, the Monthly Benefit described in this certificate will not be affected if: [the claimant's] insurance ends . . . ." Id. at MET 00271. Thus the Plan contemplates that a claimant who loses his employment after becoming disabled is eligible for benefits even though his insurance coverage ends with his employment.

Mirocha says that by May 2010, he began experiencing weakness, pain, and instability in his right shoulder, for which he sought medical attention. On May 21, 2010, Dr. Edward Joy performed an MRI on Mirocha's right shoulder and found " [m]oderate degenerative changes," a " near full-thickness tear along the anterior margin of the supraspinatus insertion," and a " SLAP tear with posterior extension." Id. at MET 00119.

Mirocha's other and possibly more significant health issue involved neurological problems. He suffered from painful headaches, and in late March 2011 he was referred for an MRI. On March 30, 2011, Dr. Raymond Dipasqou performed an MRI on Mirocha's head. The MRI revealed " innumerable hyperintensities of the periventricular and subcortical white matter." The examiner, Dr. Michael Micaletti, concluded: " Impression: 1. Extensive nonspecific periventricular and subcortical white matter disease. Considerations included demyelination. Small vessel ischemia/vasculopathy or postinflammatory process are other possibilities." Id. at MET 00118. Mirocha says this report reveals an " extensive brain disease." Compl. ¶ 10.

On April 8, 2011, PCH terminated Mirocha's employment. PCH recorded the discharge as " due to Inability to do Job/Poor Work Performance." Pl.'s Stat. of Material Facts ¶ 12. The parties disagree about what led to the termination. MetLife contends that Mirocha was terminated for

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poor job performance. It says that during the time leading up to the termination, PCH made efforts to improve Mirocha's job performance, to no avail. Record at MET 00023. Mirocha, on the other hand, alleges that his termination stemmed from his inability to perform his occupation due to his medical conditions.

About a year later, Mirocha obtained additional medical evaluations of his physical and mental limitations. On June 1, 2012, Mirocha was given an MRI on his left shoulder in response to a complaint of pain, which he later claimed to be more intense than the pain from his right shoulder. The MRI did not reveal any tears of the rotator cuff or other tendons, but the report indicates Mirocha had bicep tendonitis. Id. at MET 00122-23.

Mirocha also applied for Social Security disability benefits and underwent two independent medical examinations as part of the application process. Clinical psychologist Dr. Joan Hakimi, who performed a psychological evaluation of Mirocha, noted that " [h]e appears to be of average intelligence and his cognitive functioning is good in all areas assessed except judgment and problem-solving, which is poor." Id. at MET 00176. Dr. Kimberly Middleton performed a physical examination of Mirocha. She concluded that " [t]he claimant has marked limitations of both shoulders and would not be able to perform work as an electrician. . . . His alleged spontaneous vision loss and headaches appear credible and would affect his ability to maintain gainful work." Id. at MET 00180.

The Social Security Administration (SSA) determined that Mirocha was disabled and that his disability began on April 1, 2011, one week before his termination from PCH and while he still had coverage under the LTD insurance.

On February 25, 2013, Mirocha applied to MetLife for disability benefits. In support, he submitted in support the MRI of his brain, the MRIs of both shoulders, Dr. Hakimi's psychological examination, Dr. Middleton's physical examination, and the SSA's determination that he was disabled as of April 1, 2011. He also submitted MetLife's application form. On this form, Mirocha described his limitations relating to his return to work as " extensive white matter brain disease, torn right shoulder, pain, fatigue, migraine headaches, periodic episodes of temporary blindness, delayed recall, confusion." Id. at MET 00154. Mirocha's application listed a disability onset date of April 1, 2011, the same date the SSA had found. See id. at MET 00149.

On March 5, 2013, MetLife denied Mirocha benefits " for the period of disability beginning April 8, 2011." Id. at MET 00076. MetLife's letter, addressed to Mirocha's attorney, noted that Mirocha's employment was terminated on that date, and it quoted the portion of the Plan that states that insurance ends on the date an employee's employment ends or he ceases being in an eligible class. Id. The next sentence of MetLife's letter stated, " Therefore, based on the information obtained for our review your client is not eligible for Long-Term Disability benefits." Id. (emphasis added). The letter made reference to the SSA's award of disability benefits, saying that MetLife had taken this into consideration but that the SSA's determination " is separate from and governed by different standards than MetLife's review and determination" under the Plan. Id. However, MetLife's letter said nothing about Mirocha's medical condition and did not explain how any difference between Social Security ...


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