Arquilla-Romeo v. Metropolitan Life Insurance

980 F. Supp. 2d 847, 2013 WL 5442280, 2013 U.S. Dist. LEXIS 139331
CourtDistrict Court, N.D. Ohio
DecidedSeptember 27, 2013
DocketCase No. 4:12-cv-01779
StatusPublished
Cited by1 cases

This text of 980 F. Supp. 2d 847 (Arquilla-Romeo v. Metropolitan Life Insurance) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Arquilla-Romeo v. Metropolitan Life Insurance, 980 F. Supp. 2d 847, 2013 WL 5442280, 2013 U.S. Dist. LEXIS 139331 (N.D. Ohio 2013).

Opinion

ORDER

JOHN R. ADAMS, District Judge.

This matter is before the Court on the parties cross motions for judgment on the administrative record, Documents 17 and 18, and Defendant Metropolitan Life Insurance Company’s motion for summary judgment on its counter-claim for repayment of overpayment of benefits to Plaintiff Arquilla-Romeo, Document 18. The motions are fully briefed and ripe for review.

I. Introduction

This action arises under the Employee Retirement Income Security Act of 1974 (“ERISA”), as amended, 29 U.S.C. §§ 1001 et seq, and concerns Defendant Metropolitan Life Insurance Company’s (“MetLife”) termination of Plaintiff Renee Arquilla-Romeo’s (“Arquilla-Romeo”) long term disability (“LTD”) benefits she had been receiving under the Siemens Corporation Group Insurance and Flexible Benefits Program (the “Plan”) sponsored by her employer, Siemens Corporation (“Siemens”), and funded by a group insurance policy issued to Siemens by MetLife.

During the administrative process, Met-Life determined that Arquilla-Romeo’s disability stems from a “neuromusculoskeletal and soft tissue disorder” thereby limiting her to a 24 month period for benefits. Arquilla-Romeo argues that her disability does not include a “soft tissue disorder” and, therefore, the 24 month limitation period is not triggered.

II. Standard of Review

In order to determine the standard of review herein, this Court must first decide whether the Plan vests discretionary authority in MetLife. On this issue, the parties disagree. The Sixth Circuit, in Frazier v. Life Ins. Co. of North America, recently articulated the standard of review that a district court applies after the administrator of a benefit plan denies benefits:

Under ERISA, a denial of benefits “is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Majestic Star Casino, 581 F.3d at 364-65. If the administrator or fiduciary can show it has such discretionary authority, a benefits denial is reviewed under the arbitrary and capricious standard. Haus [v. Bechtel Jacobs Co., 491 F.3d 557, 561-62 (6th Cir.2007) ] (internal quotation marks omitted). Although “magic words” are not required, this Court “has consistently required that a plan contain a clear grant of discretion” to the administrator or fiduciary before applying the deferential arbitrary and capricious standard. Perez v. Aetna Life Ins. Co., 150 F.3d 550, 555 (6th Cir.1998) (internal quotation marks omitted, emphasis in original). A plan is not required to, but “may expressly provide for procedures for allocating fiduciary responsibilities.” 29 U.S.C. § 1105(c)(1).

725 F.3d 560, 566 (6th Cir.2013).

Arquilla-Romeo argues that a de novo standard of review applies. Arquilla-Romeo acknowledges that the ERISA statement attached to the Plan attempts to give MetLife discretion over the interpretation of the Plan; she argues, however, that the ERISA attachment is not a part of the terms of the Plan and, therefore, does not [850]*850grant clear discretion to MetLife. There are numerous district courts that have held that a grant of discretion not contained in the plan certificate itself is invalid to invoke an arbitrary and capricious standard of review. MetLife disagrees and argues that the ERISA attachment is part of the Plan.

This Court need not reach a decision as to whether the ERISA attachment to the Plan certifícate confers discretion to MetLife. The certificate of insurance, at page ii, expressly provides: “MetLife in its discretion has authority to interpret the terms, conditions, and provisions of the entire contract. This includes the Group Policy, Certificate, and any Amendments.” Moreover, the certificate of insurance provides that, to receive benefits under the Plan, a participant must provide supporting documentation “subject to [MetLife’s] satisfaction ...” MetLife has properly argued that the Sixth Circuit has held that this language invokes the arbitrary and capricious standard of review. “Yeager v. Reliance Std. Life Ins., 88 F.3d 376, 381 (6th Cir.1996) (finding that language stating that claimant must submit “satisfactory proof of Total Disability to us” conferred discretion); Perez v. Aetna Life Ins. Co., 150 F.3d 550, 556 (6th Cir.1998) (en banc) (language stating that the insurer “shall have the right to require as part of the proof of claim satisfactory evidence” conferred discretion); Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 983 (6th Cir.1991) (language requiring “medical evidence satisfactory to the Insurance Company” conferred discretion).” Doc. 20 at 2. Accordingly, this Court must review Met-Life’s termination of Arquilla-Romeo’s LTD under the arbitrary and capricious standard.

“[T]he arbitrary or capricious standard is the least demanding form of judicial review of administrative action and when it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious.” Davis v. Kentucky Finance Cos. Retirement Plan, 887 F.2d 689, 693 (6th Cir.1989). A decision to terminate benefits is not arbitrary and capricious if it was the product of deliberate principled decision making and based on substantial evidence. Killian v. Health-source Provident Administrators, Inc., 152 F.3d 514, 520 (6th Cir.1998). A plan administrator’s 1 inherent conflict of interest by virtue of being both sole decision maker and sole payor should also be taken into account. Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299, 311 (6th Cir.2010); Calvert v. Firstar Finance, Inc., 409 F.3d 286, 292 (6th Cir.2005) (citations omitted).

In determining whether a plan administrator’s decision to deny LTD benefits was arbitrary and capricious, a court may not substitute its own judgment for that of the administrator. Brown v.

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980 F. Supp. 2d 847, 2013 WL 5442280, 2013 U.S. Dist. LEXIS 139331, Counsel Stack Legal Research, https://law.counselstack.com/opinion/arquilla-romeo-v-metropolitan-life-insurance-ohnd-2013.