United States District Court, N.D. Indiana, Fort Wayne Division
[Copyrighted Material Omitted]
[Copyrighted Material Omitted]
For Kathleen Boxell, Plaintiff, Counter Defendant: Robert J Rosati, ERISA Law Group LLP, Fresno, CA.
For The Plan for Group Insurance of Verizon Communications Inc, Defendant, Counter Claimant: Tina M Bengs, LEAD ATTORNEY, Ogletree Deakins Nash Smoak & Stewart PC - Val/IN, Valparaiso, IN.
OPINION AND ORDER
JON E. DEGUILIO, United States District Judge.
This is an ERISA case in which the plaintiff, Kathleen Boxell, asserts that her long-term disability benefits were wrongfully terminated. The defendant, the Plan for Group Insurance of Verizon Communications Inc., filed a counterclaim seeking reimbursement of overpayments that resulted from Ms. Boxell's receipt of retroactive social security benefits. The parties have filed cross-motions for summary judgment as to both claims, [DE 38, 40], and those motions are fully briefed. The Plan also filed motions to strike exhibits that Ms. Boxell attached to her opening and response briefs, and in addition to opposing those motions, Ms. Boxell moved in the alternative for leave to amend her complaint. Each of these preliminary motions has been fully briefed as well. For the following reasons, the Court denies the motions to strike and the motion for leave to amend, grants Ms. Boxell's motion for summary judgment as to her claim for benefits, and grants the Plan's motion for summary judgment, but only as to its counterclaim for reimbursement.
I. FACTUAL BACKGROUND
Ms. Boxell was employed by Verizon Communications Inc. as a Network Engineer. (R. 128). Her job required her to sit at her desk and work on her computer for about 95% of her time, although she occasionally had to visit job sites as well. (R. 108, 129). In 2009, Ms. Boxell began experiencing pain in her lower back and in both legs, and initial tests suggested she may have Paget's disease in her L5 vertebrae, a disorder characterized by abnormal bone growth that can cause bones to become fragile or misshapen. Ms. Boxell saw several specialists, but the source of her pain and her precise diagnosis remained unclear. Although Ms. Boxell was initially able to work through the pain, it gradually became worse and interfered with her ability to work. (R. 110). On September 29, 2009, with the approval of her doctor, Ms. Boxell went on medical leave and sought disability benefits.
A. The Plan
As a Verizon employee, Ms. Boxell was eligible to receive short-term and long-term disability benefits under the Plan for Group Insurance, an employee benefit plan governed by the Employee Retirement Income Security Act. Under the Plan, employees are eligible to receive short-term disability benefits for up to 12 months if they become totally disabled. (R. 17). Employees are considered " totally disabled" if, " as a result of illness, injury or pregnancy," they (1) " are unable to perform
the essential functions of [their] own job" ; (2) " are not working at another job" ; and (3) " are receiving appropriate care and treatment from a doctor on a continuing basis." ( Id.).
Claimants who remain totally disabled after exhausting their 12 months of short-term disability benefits can then begin receive long-term disability benefits. (R. 31). To be eligible for these benefits, claimants must be totally disabled, be under the care of a doctor, and be undergoing appropriate care and treatment. (R. 33-34). In addition, during the first 12 months of receiving long-term disability benefits, claimants must be " unable to earn more than 80% of [their] annual benefits compensation at [their] own occupation," and thereafter, they must be " unable to earn more than 60% of [their] annual benefits compensation from any employer at any gainful occupation" to remain eligible for benefits. (R. 34).
The Plan also contains limitations on the amount of long-term disability benefits that are payable where a claimant's disability is due to certain types of conditions. Most relevant here, the Plan contains a provision limiting benefits for neuromusculoskeletal and soft tissue disorders, which states:
Long-term disability (LTD) benefits are limited to 12 months during your lifetime if you are totally disabled due to a neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue. This includes sprains and strains of joints and adjacent muscles, unless the disability has objective evidence of: seropositive arthritis; spinal tumors, malignancy or vascular malformations; radiculopathies; myelopathies; traumatic spinal cord necrosis; [or] musculopathies.
(R. 41). The Plan contains definitions for some, but not all, of those terms.
The Plan also requires all claimants to apply for social security disability benefits, and to appeal any adverse decisions through the entire administrative appeals process. (R. 36). If claimants receive an award social security disability benefits, those benefits reduce the benefits payable by the Plan by an equal amount. (R. 36). Further, when claimants receive retroactive awards of social security disability benefits, those benefits retroactively reduce the amounts payable by the Plan as well, and the Plan reserves the right to recover any excess payments it may have made in those prior periods. (R. 37, 56).
The Plan names MetLife as the claims administrator, and gives it " authority to make final determinations regarding eligibility and benefit claims under the disability income protection program." (R. 46-47). The Plan further vests MetLife with the discretionary authority to interpret the Plan, make factual determinations, and determine whether a claimant is eligible for benefits. (R. 47). However, MetLife bears no financial responsibility for the benefits under the Plan--benefits are paid from trust accounts that are self-insured and that are funded through employer or employee contributions. (R. 47).
B. The Claim History
Ms. Boxell filed a claim for short-term disability benefits on September 29, 2009, citing back pain that was exacerbated by sitting at her desk all day and by driving. (R. 108). MetLife processed the claim, and determined that Ms. Boxell qualified as disabled and was entitled to short-term disability benefits for about a three-week period. (R. 131). MetLife subsequently extended her benefits on multiple occasions, as despite her treatment, Ms. Boxell remained unable to return to work. (R.
142-54, 162-63, 165, 206, 228). On January 6, 2010, Ms. Boxell received a Functional Capacity Evaluation, which found that due to the pain in her lower back and legs, Ms. Boxell was limited to sitting only occasionally. (R. 3049). Dr. Joseph Mattox, Ms. Boxell's primary care physician, also stated that she should not return to work due to her chronic pain and the effects of her narcotic pain medication. (R. 4222).
On June 18, 2010, Ms. Boxell began seeing a new pain management specialist, Dr. Joseph Fortin. (R. 4061). Dr. Fortin's impressions were that Ms. Boxell suffered from Paget's disease and chronic low back pain, but he was unsure of the precise cause of the pain. (R. 4064). On July 13, 2010, Dr. Fortin responded to several questions posed by MetLife relative to Ms. Boxell's disability, and he recommended no prolonged sitting, standing, or walking, and stated that Ms. Boxell must change positions every 15 to 20 minutes. (R. 4060). Dr. Fortin also made similar recommendations in completing functional capacity assessments on September 10 and 28, 2010. (R. 4005, 3977)
On October 6, 2010, MetLife extended Ms. Boxell's short-term disability benefits through their maximum duration of 12 months, and referred her file to its long-term disability benefits division. (R. 3972). Shortly thereafter, MetLife determined that Ms. Boxell was eligible to receive long-term disability benefits under the Plan. (R. 3968). In its letter notifying Ms. Boxell of this decision, MetLife stated that the " medical documentation on file substantiates that you currently meet the definition of totally disabled." (R. 3970). MetLife also indicated that because of a limitation provision in the Plan, these benefits would be only be payable for 12 months, absent additional findings:
Our records indicate that you are disabled due to low back pain and bilateral lower extremity pain, conditions which The Plan places a limit on the number of benefit payments payable. The condition is limited to twelve months of benefits under this policy. Therefore, the maximum benefit duration due to the limited condition will be reached on September 28, 2011. In order to qualify for disability benefits until September 28, 2011, you must continue to satisfy the definition of disability and all other requirements of you plan.
Benefits may continue after September 28, 2011 if you continue to satisfy the definition of disability solely due to other non-limited medical condition(s) and other plan requirements.
(R. 3970). MetLife also notified Ms. Boxell that the Plan required her to apply for social security disability benefits, and it referred her to attorneys to assist her with that claim. (R. 3963).
On December 21, 2010, Dr. Fortin and Dr. Mattox each completed a functional capacity assessment for Ms. Boxell. Dr. Fortin's recommendation remained the same, as he stated that due to Ms. Boxell's chronic low back pain and bilateral leg pain, Ms. Boxell could not sit, stand, or walk for prolonged periods and that she must change positions every 15 to 20 minutes. (R. 3919). Dr. Fortin also indicated that he had advised Ms. Boxell not to return to work. (R. 3918). Dr. Mattox offered a different opinion, though. He stated that Ms. Boxell was able to work without any physical limitations at all, that she was able to sit, stand, and walk continuously for eight hours a day, and that she could immediately return to work full time. ( Id.). MetLife received this assessment, but noted in its claims log that Dr. Mattox's opinion " is contradictory to Dr. Fortin and does not address the severity of
Paget[']s disease." (R. 348). In a subsequent medical review of Ms. Boxell's file, MetLife concluded that " Medical continues to support functional limitations to prevent performance of her own job." (R. 361).
On December 30, 2010, Dr. Fortin also diagnosed Ms. Boxell with fibromyalgia, stating in his office visit notes that " [p]alpation reveals tender points consistent with fibromyalgia." (R. 3895). Dr. Fortin prescribed Cymbalta for that condition, and further noted that " [p]ain control is felt to be 'not so good.'" (R. 3894-95). In subsequent monthly office visits, Dr. Fortin listed his impressions as including " Diffuse myalgias, arthralgias, and paresthesias secondary to fibromyalgia syndrome" and " History of Paget's disease." (R. 3899, 3892, 3887, 3884, 3875). Having been diagnosed with fibromyalgia, Ms. Boxell asked MetLife whether this condition was also subject to a 12-month limitation under the Plan. (R. 370). The claims specialist was initially unsure, but an April 28, 2011 entry in the claims log states, " Claimant remains under treatment with pain management for chronic diffuse pain, myalgias, paresthesias secondary to Fibromyalgia, which is an LDB [Limited Disability Benefit] condition." (R. 401). MetLife informed Ms. Boxell the following day that her fibromyalgia was subject to the limitation provision, and that her long-term disability benefits were still set to terminate on September 28, 2011. (R. 403).
On September 16, 2011, shortly before the 12 month period expired, MetLife sent Ms. Boxell a letter formally advising her that her long-term disability benefits were terminating. (R. 3841). The letter stated:
In reviewing your file, the medical documentation indicates that you are disabled due to low back pain and fibromyalgia, Neuromusculoskeletal/Soft Tissue conditions. These diagnoses fall under the limited benefit provision of your Plan, and has [ sic ] a limitation of 12 months. Therefore the maximum duration for benefit payments is September 28, 2011.
(R. 3841). MetLife advised Ms. Boxell that she could appeal this decision within 180 days, and it invited her to submit any additional evidence that would " support a disability other than neuromuscular, musculoskeletal, or soft tissue disorder and/or that support[s] an exclusion to the provision." (R. 3842). In a phone call to Ms. Boxell around that time, a claims representative told Ms. Boxell, " [W]e are not questioning disability. Plan has a LBC [Limited Benefit Condition] clause." (R. 446).
Ms. Boxell retained counsel, and on March 13, 2012, her counsel submitted an appeal of MetLife's decision, accompanied by a lengthy letter and nearly one thousand pages of exhibits. (R. 2755). The letter is littered with ad hominem attacks on MetLife and its practices. As to Ms. Boxell's claim in particular, the letter primarily argued that Ms. Boxell's Paget's disease was the source of her disability, and that it fell within an exception to the limitation for neuromusculoskeletal and soft tissue disorders because it was a myelopathy, so that Ms. Boxell's benefits should have continued beyond the 12-month limitation. (R. 2758).
MetLife took the appeal under consideration and retained Dr. Neil McPhee, a consultant, to independently review Ms. Boxell's claim. MetLife posed four ...