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Hennen v. Metropolitan Life Insurance Co.

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

September 20, 2017

Susan Hennen, Plaintiff,
v.
Metropolitan Life Insurance Company Defendant.

          MEMORANDUM OPINION & ORDER

          Thomas M. Durkin United States District Judge

         Plaintiff Susan Hennen (“Hennen”) received long-term disability benefits from Defendant Metropolitan Life Insurance Company (“MetLife”) under the provisions of NCR Corporation's long-term disability benefits plan (the “Plan”). The Plan limited long-term disability benefits for Hennen's impairment to 24 months in the absence of objective evidence of a condition called radiculopathy. MetLife determined that Hennen failed to present such evidence at the end of the 24-month period and terminated Hennen's benefits. Hennen sued MetLife under the Employee Retirement Income Security Act (“ERISA”) to challenge this decision.

         Hennen and MetLife have filed cross-motions for summary judgment. R. 25; R. 29. Both parties seek fees and costs. Id. For the reasons explained below, MetLife's motion for summary judgment is granted, and Hennen's motion for summary judgment is denied. MetLife's request for fees and costs is denied.

         Background[1]

         A. NCR Corporation's Long-Term Disability Benefits Plan

         The material facts in this case are undisputed. While employed by NCR Corporation, Hennen received long-term disability (“LTD”) coverage under the Plan, which is funded by a group insurance policy issued by MetLife. PSMF ¶¶ 17, 20; DSMF ¶¶ 8, 18.

         Under the Plan, “‘Disability' means that due to sickness, pregnancy, or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis.” DSMF ¶ 3; PR ¶ 3. In a section titled “Limitation For Disabilities Due to Particular Conditions, ” the Plan explains that “Monthly Benefits are limited to 24 months during your lifetime if you are Disabled due to a . . . Neuromusculoskeletal and soft tissue disorder . . . unless the Disability has objective evidence of . . . radiculopathies.” PSMF ¶¶ 8, 9; DSMF ¶ 4.

         The Plan defines “[n]euromusculoskeletal and soft tissue disorder” as “any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles.” PSMF ¶ 8; DSMF ¶ 4. The Plan defines “radiculopathies” as “[d]isease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.” PSMF ¶ 9; DSMF ¶ 4.

         B. Hennen's Medical History

         Hennen has a long history of low-back problems. She had low-back surgeries in 2003 and 2008 while working as a sales specialist for NCR Corporation. PSMF ¶¶ 11, 13; DR ¶¶ 11, 13.

         Following a third surgery in September 2012 for a herniated disk, MetLife approved Hennen's claim for LTD benefits. PSMF ¶ 20; DSMF ¶ 18. MetLife's letter to Hennen awarding benefits explained that she satisfied the Plan's definition of “[n]euromusculoskeletal and soft tissue disorder” and that “the maximum benefit duration due to th[is] limited condition will be reached on November 11, 2014 . . . . Benefits may continue after November 11, 2014 if you continue to satisfy the definition of Disability solely due to other non-limited medical condition(s) and other plan requirements . . . .” PSMF ¶ 20; DSMF ¶ 18.

         Hennen's spine surgeon Dr. Frank Phillips noted in his operative report for the September 2012 surgery that Hennen's “nerves were free of compression and mobile.” DSMF ¶ 16; PR ¶ 15. In a December 2012 office note, Dr. Phillips stated that Hennen had “good improvement in her back pain, ” and her continuing symptoms “probably represent[ed] some residual nerve pain.” PSMF ¶ 22; DSMF ¶ 20. Dr. Phillips ordered an MRI to “rule out any recurrent or residual neural compression.” DSMF ¶ 20; PR ¶ 20. The MRI showed “stable” post-surgical changes “without significant stenosis.” DSMF ¶ 21; PR ¶ 21.

         Hennen then began pain management treatment with anesthesiologist and pain management specialist Dr. Asokumar Buvanendran. PSMF ¶ 24; DSMF ¶¶ 16, 22. In February 2013, Dr. Buvanendran diagnosed Hennen with “[l]umbar radiculopathy.” PSMF ¶ 28; DSMF ¶ 22.

         Hennen had another low-back surgery in April 2013 to implant an epidural spinal cord stimulator. PSMF ¶ 29; DSMF ¶ 23. Hennen experienced a dramatic reduction in pain after that surgery. PSMF ¶ 29; DSMF ¶ 23.

         In May 2014, Hennen had another surgery: a left hip arthroscopy with orthopedic surgeon Dr. Shane Nho to repair a muscle tear sustained during a fall. PSMF ¶ 35; DSMF ¶¶ 24, 26. An MRI of Hennen's hip prior to the surgery demonstrated the muscle tear, but also showed that “[t]he neurovascular bundles are grossly intact, with no extrinsic compression.” DSMF ¶ 25; PR ¶ 25. After the surgery, Dr. Nho informed MetLife that he estimated Hennen could return to work by August 15, 2014. DSMF ¶ 26; PR ¶ 26.

         Post-surgery, Hennen continued to report shooting nerve pain down her leg. PSMF ¶ 36; DR ¶ 36. In a questionnaire completed for MetLife in July 2014, Dr. Buvanendran again diagnosed Hennen with “lumbar radiculopathy.” PSMF ¶ 37; DR ¶ 37.

         In August 2014, Dr. Nho submitted an attending physician's statement to MetLife explaining that Hennen's hip was “structurally sound, ” noting that Hennen's pain was likely “back and neuropathic related, ” and referring her care to Dr. Buvanendran. PSMF ¶ 39; DSMF ¶ 28.

         C. MetLife's Termination Of Hennen's Benefits

         MetLife contacted Hennen by telephone on August 15, August 18, and September 18, 2014 to explain that an MRI or electromyogram (“EMG”) was required to determine if her condition fell within the radiculopathies exception to the Plan's 24-month benefit limitation for neuromusculoskeletal and soft tissue disorders. DSMF ¶¶ 29, 30, 32; PR ¶¶ 29, 30, 32. MetLife sent a letter to Hennen on October 13 explaining that it planned to terminate her benefits on November 11. PSMF ¶ 41; DSMF ¶ 33. The letter informed Hennen of her right to an administrative appeal, explaining that any appeal should include objective findings including “Current test results (MRI, CT, EMG).” DSMF ¶ 33; PR ¶ 33.

         On October 17, Dr. Buvanendran sent MetLife a letter reaffirming his diagnosis of lumbar radiculopathy. PSMF ¶ 42; DR ¶ 42. He included a copy of a recent, September 2014 MRI. PSMF ¶ 45; DSMF ¶ 35. MetLife consulted with its medical doctor, Dr. David Peters, who found that Hennen's September 2014 “MRI does not reveal ongoing nerve root or spinal cord compression that would support a current diagnosis of lumbar radiculopathy.” PSMF ¶ 46; DSMF ¶¶ 31, 36. Hennen's LTD benefits terminated in November 2014.

         Hennen appealed MetLife's determination in July 2015. She submitted an EMG from June 2015 in support of her appeal. PSMF ¶¶ 47-48; DSMF ¶¶ 38-40. The fellow-in-training, Dr. Joseph Kipta, who administered Hennen's EMG stated in the “Impression” section of his report that Hennen's “superficial peroneal sensory responses” constituted “evidence to support left lumbar motor polyradiculopathies.” PSMF ¶ 48; DSMF ¶¶ 38-40. But he commented that “[n]o abnormal spontaneous or insertional activity was noted in any of the muscles examined” during the EMG. DSMF ¶ 39; PR ¶ 39. He explained that “[f]urther clinical correlation is advised.” DSMF ¶ 40; PR ¶ 40. In July 2015, MetLife consulted its medical doctor certified in family medicine, Dr. Dupe Adewunmi, who opined that the EMG supported a diagnosis of radiculopathy. DSMF ¶ 42; PR ¶ 42.

         In a claims note later that month, MetLife's appeal specialist observed that the Plan specifies that, during an administrative appeal, “MetLife will consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment.” DSMF ¶¶ 6, 43; PR ¶¶ 6, 43. Around this time, MetLife learned that the Social Security Administration had denied Hennen's claim for disability income benefits at the initial application stage. DSMF ¶ 41; PR ¶ 41.

         MetLife then consulted Dr. Neil McPhee, who is board certified in physical medicine and rehabilitation. PSMF ¶ 53; DSMF ¶ 44. In August 2015, after reviewing Hennen's medical records, Dr. McPhee submitted a 27-page report finding that Hennen's December 2012 and September 2014 MRIs showed no radiculopathy, and that her June 2015 EMG likewise “was negative for active radiculopathy.” PSMF ¶ 54; DSMF ¶¶ 44-45.

         MetLife sent Dr. McPhee's analysis to Hennen's attorney and Dr. Buvanendran, who both responded with letters protesting and disputing Dr. McPhee's conclusions. PSMF ...


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