Francis Garcia v. Raytheon et a l . CV-98-595-B 12/4/00
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE
Francis Garcia
v. Civil No. 98-595-B Opinion No. 2000DNH256 Raytheon Employees Disability Trust and Metropolitan Life Insurance Company
MEMORANDUM AND ORDER
Francis Garcia brings this action pursuant to the Employee
Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)
( B ) , to recover benefits allegedly due to him under the terms of
the Raytheon Long Term Disability Plan (the “Plan”). Garcia
alleges that the decision of defendant Metropolitan Life
Insurance Company (“MetLife”), the claims administrator under the
Plan, to terminate his disability benefits was arbitrary and
capricious. Before me are Garcia’s motion for judgment on the
administrative record (doc. n o . 19) and defendants’ motion for
judgment on the administrative record (doc. n o . 2 0 ) . 1 For the
1 On January 1 0 , 2000, I issued a margin order: (1) denying defendants’ motion for summary judgment (Doc. N o . 9 ) ; (2) ordering defendants to file a copy of the administrative record reasons set forth below, I deny Garcia’s motion and grant the
defendants’ motion.
I. BACKGROUND2
After retiring from his position as a Corrections Officer
with the Massachusetts Department of Corrections, Francis Garcia
went to work for Raytheon as a security guard in 1987. As a
Raytheon employee, Garcia was eligible to participate in the
Plan.
A. The Plan
The Plan divides benefit eligibility into two phases.
During the initial phase of up to twenty-four months, an employee
is eligible for benefits if he is found to be “fully disabled.”
The Plan defines “fully disabled” as unable to perform
substantially all of the duties of the employee’s job at Raytheon
even with a reasonable accommodation. In the second phase, an
in this case with the court; and (3) requiring plaintiff to file a motion and memorandum explaining why he is entitled to judgment on the administrative record and requiring defendants to respond thereto. 2 The background facts set forth herein are taken from the administrative record filed with this court by the defendants.
-2- employee is eligible for benefits only if he is found to be
“totally disabled,” meaning that the employee can not: (1)
perform the essential elements and substantially all of the
duties of his job at Raytheon even with reasonable accommoda-
tions; and (2) perform any other job for which he is fit by
education, training, or experience. The burden is on the
employee to provide satisfactory proof of the nature and extent
of his disability.
B. Phase One: Garcia’s Claim for Disability Benefits
In January 1988, Dr. Khawaja Rahman, a neurologist, examined
Garcia. Garcia complained of occasional numbness in the fingers
of his left hand, in his left leg and foot, and in his neck, as
well as incontinence. Dr. Rahman found that Garcia had decreased
sensitivity on his left side. Garcia’s symptoms disappeared
shortly thereafter.
Garcia’s symptoms reemerged later that year and in December
1988 he went to see D r . Rahman again. After having a number of
tests performed, including an MRI and CAT scan, D r . Rahman’s
assessment of Garcia’s condition was “probable multiple
-3- sclerosis.”3
Garcia did not return to work after seeing Dr. Rahman.
Citing numbness in his extremities, he applied for disability
benefits under the Plan in March 1989. His claim was approved
and he began receiving benefits in April 1989.
In connection with Garcia’s application for benefits, Dr.
Rahman submitted an Attending Physician’s Statement of Functional
Capacity (“SFC”) to MetLife in May 1989. On that form, D r .
Rahman listed the limitations that Garcia’s medical condition
placed on his ability to perform certain activities. According
to Dr. Rahman, Garcia should completely avoid: assuming cramped
positions; grasping/handling; climbing stairs, ladders, or
scaffolds; operating heavy equipment; and operating electrical
equipment. Garcia had “some limitation” with regard to the
following activities: transportation; standing; sitting; reaching
forward or overhead; pushing, pulling, or twisting; finger
3 Multiple sclerosis is the occurrence of patches of sclerosis, or plaques, in the brain and spinal cord, causing some degree of paralysis, tremor, nystagmus, and disturbances of speech. The various symptoms depend upon the location of the lesions. It occurs chiefly in early adult life, with characteristic exacerbations and remissions. Stedman’s Medical Dictionary 1393 (25th ed. 1990).
-4- dexterity; repetitive movement; and operating a dolly or small
vehicle. He had no limitation with regard t o : change of position
(sitting/standing); bending, stooping, or squatting; or
concentrated visual attention. Dr. Rahman, while noting that
Garcia’s condition had improved, also concluded that Garcia was
“totally disabled” for any occupation, including his security
guard position. D r . Rahman noted that he could not determine
when Garcia would be able to resume work activities.
Just a few months later, in August 1989, Dr. Rahman
submitted a new SFC and concluded that Garcia was no longer
totally disabled. While Garcia’s condition had improved, D r .
Rahman noted that he could not determine when Garcia would be
able to return to work.
In November 1989, Dr. Rahman found that Garcia’s condition
had not improved. Once again, he concluded that Garcia was
totally disabled for any occupation. In March 1990, Dr. Rahman
found no change in Garcia’s condition and, for the first time,
noted that Garcia would “never” be able to resume work
activities. Subsequent SFC’s completed by Dr. Rahman in August
1990 and January 1991 contained the same conclusions.
C. Phase Two: Examinations and Assessments
-5- By February 1992, Garcia had entered the second phase of
benefit eligibility under the Plan, in which he was required to
show that he was totally disabled. Dr. Rahman concluded, in five
SFC’s submitted between February 1992 and June 1995, that Garcia
remained totally disabled.
In June 1995, Raytheon medical personnel examined Garcia.
The examining physician, whose identity is not clear from the
record, concluded that although Garcia’s condition imposed
certain physical limitations upon him, he was not totally
disabled. After reviewing this assessment, Raytheon concluded
that they could accommodate Garcia’s restrictions and he could
return to work as a security guard. MetLife informed Garcia of
this decision in July 1995.
Dr. Rahman disagreed with MetLife’s assessment of Garcia’s
work capability. MetLife then referred Garcia to Dr. Michele
Masi, who examined Garcia in September 1995. At this examina-
tion, Garcia stated that he had been using a cane to walk since
1988 and that he had fallen several times. He complained of
numbness and unsteadiness in his left side, chronic fatigue, and
problems with his memory. Dr. Masi found that Garcia had reduced
strength and sensory perception on his left side, as well as
-6- significant cognitive deficits including short term memory
difficulties. She concluded that he had chronic progressive
multiple sclerosis and that his condition was unlikely to
improve. Based on that assessment, and “particularly in light of
the cognitive deficits noted today,” she concluded that Garcia
was totally disabled.
Despite D r . Masi’s assessment, Raytheon continued to review
Garcia’s claim. As part of that review, Raytheon hired a private
investigator to observe Garcia’s daily activities and to inter-
view his neighbors in January and April 1996. The private
investigator observed that Garcia walked with a limp but did not
use a cane. He also observed Garcia driving his car and visiting
with friends. According to the investigator, Garcia’s neighbors
told him that Garcia “kept busy,” did his own yardwork, and
shoveled his own snow.
In March 1996, as part of their review of Garcia’s claim,
MetLife asked Dr. George Lim to review Garcia’s medical file and
the private investigator’s reports. Dr. Lim concluded that
Garcia’s “physical activity seems to allow some level of work”
and he recommended that MetLife ask for objective medical
evidence to confirm Dr. Rahman’s diagnosis of multiple sclerosis.
-7- In May 1996, MetLife asked a member of an independent medical
-8- consulting group, Dr. Robert Petrie, to review Garcia’s file more
fully.
Dr. Petrie questioned the diagnosis of multiple sclerosis
and concluded that Garcia was not totally disabled. He noted
that Garcia’s primary impairment was weakness in his left leg but
that Garcia could walk without a cane. He also noted that Dr.
Masi’s finding of cognitive deficits conflicted with the reports
of Dr. Rahman, who had consistently found no such deficits in
his many examinations of Garcia. He found that Garcia was
employable, but with restrictions on standing, walking, lifting,
and other activities. Raytheon’s medical personnel agreed with
this assessment and concluded that they could accommodate
Garcia’s restrictions in his position as a security guard.
In July 1996, another Raytheon physician, D r . Martha
Lipchitz, examined Garcia. She noted that Garcia walked with a
cane and with an unsteady gait. Dr. Lipchitz opined that Garcia
could attempt a sedentary job where he was allowed to stand up
and stretch, as needed, and use a cane.
Based upon a review of the evidence, MetLife concluded, in
August 1996, that there was insufficient objective medical
evidence to support the conclusion that Garcia was “totally
-9- disabled.” Accordingly, MetLife terminated Garcia’s benefits.
Garcia appealed this decision.
D. Garcia’s Appeal
In response to Garcia’s appeal, Dr. Petrie again reviewed
Garcia’s medical file, which now included the most recent
evaluation performed by Dr. Rahman. Dr. Petrie did not change
his initial assessment that Garcia was employable.
MetLife subsequently obtained a vocational assessment of
Garcia, based on his medical file. The vocational assessment
company ultimately concluded that Garcia was capable of
performing semi-skilled to skilled employment at a sedentary to
light duty level, with some limitations based on his physical
condition, but that he lacked the residual functional capacity to
return to his position as a security guard at Raytheon.
According to the assessment, Garcia, based on his work
experience, was capable of employment as either a security
guard 4 , gate guard, or airline security representative.
4 The report suggests that Garcia lacked the residual functional capacity to return to his position as a security guard at Raytheon because Raytheon required its security guards to perform more heavy lifting than was normally required for such a position. Garcia, the report suggests, could work as a security guard where heavy lifting was not required.
-10- In March 1997, D r . Petrie again reviewed Garcia’s medical
file, including the recent vocational assessment report. He
opined that, regardless of the cause of Garcia’s impairments,
Garcia was not totally disabled so as to preclude employment.
On March 1 2 , 1997, after reviewing the record, MetLife
upheld its decision to terminate Garcia’s benefits. MetLife
stated that “there is insufficient evidence to demonstrate
significant impairment which would prevent Mr. Garcia from
performing semi-skilled to skilled employment.” There were no
other administrative appeals available to Garcia, who subse-
quently initiated this action.
II. STANDARD OF REVIEW
All parties agree that MetLife’s decision to terminate
Garcia’s benefits should be reviewed under the arbitrary and
capricious standard of review, sometimes referred to as the abuse
of discretion standard. Given the clear language in the Plan
granting discretionary authority to MetLife, I see no need to
disturb the parties’ assumption. See Terry v . Bayer Corp., 145
F.3d 2 8 , 37 (1st Cir. 1998) (where a benefit plan clearly grants
discretionary authority to plan administrator, arbitrary and
-11- capricious standard of review applies); see also Firestone Tire &
Rubber C o . v . Bruch, 489 U.S. 101, 115 (1989)(courts review
denial of benefits under de novo standard unless benefit plan
gives the administrator discretionary authority to determine
eligibility for benefits or to construe the terms of the plan).
Whether it is referred to as arbitrary and capricious review
or abuse of discretion review, the touchstone of this standard is
reasonableness. See Terry, 145 F.3d at 37 n.6 (“[T]here is no
need to adopt one phrase and avoid the other . . . reasonableness
. . . is our polestar.”) (quoting Block v . Pitney Bowes, Inc.,
952 F.2d 1450, 1454 (D.C. Cir. 1992)); see also Doe v . Travelers
Ins. Co., 167 F.3d 5 3 , 57 (1st Cir. 1999) (reasonableness is the
touchstone of this standard of review). In reviewing a decision
to terminate benefits, a court may not substitute its judgment
for that of the decision-maker. Terry, 145 F.3d at 40 (internal
quotations and citations omitted). Rather, under this deferen-
tial standard of review, a decision by a plan administrator must
be upheld if it was within the plan administrator’s authority,
reasoned, and supported by substantial evidence in the record.
See Doyle v . Paul Revere Life Ins. Co., 144 F.3d 181, 183-84 (1st
Cir. 1998) (internal citations and quotations omitted).
-12- Substantial evidence means “evidence reasonably sufficient to
support a conclusion.” Id. at 184; see also Recupero v . New
England Telephone and Telegraph Co., 118 F.3d 820, 830 (1st Cir.
1997) (reviewing court should not set aside a factual finding
that has adequate support in the record). “Sufficiency, of
course, does not disappear merely by reason of contradictory
evidence.” Doyle, 144 F.3d at 184. I apply this standard in
reviewing MetLife’s decision to terminate Garcia’s benefits.
III. DISCUSSION
Garcia claims that MetLife’s determination that he was not
totally disabled, and that therefore his benefits should be
terminated, was arbitrary, capricious, and an abuse of discre-
tion. Specifically, Garcia argues that MetLife ignored or
disregarded the opinions of Drs. Rahman and Masi, who examined
Garcia and concluded that he was totally disabled, and instead
focused only on the opinion of “one physician reviewing
documents.” See Pl.’s Mot. for Judgment on Admin. Record (doc.
n o . 19) at 7 . Garcia also suggests that defendants’ actions
-13- bordered on bad faith.5 Defendants respond that there was
reasonably sufficient evidence in the record to support MetLife’s
conclusion that Garcia was not totally disabled.
MetLife had authority under the Plan to determine whether
Garcia was “totally disabled.” The Plan defines that term as
meaning that an employee is unable do any other job for which the
employee is fit by education, training, or experience. I pause
here to note that “such general disability provisions should not
be construed so literally that an individual must be utterly
helpless to be considered disabled.” Doyle, 144 F.3d at 184
(quoting Hammond v . Fidelity & Guar. Life Ins. Co., 965 F.2d 428,
431 (7th Cir. 1992)) (interpreting policy term “totally
disabled”).
Implicit in Garcia’s argument are the following assumptions:
(1) that MetLife should have given controlling weight to the
opinion of Dr. Rahman because he was Garcia’s treating physician;
5 With regard to this line of argument, I note that “[a]ny inferences of bad faith . . . are weighed not in the determination of whether the decision was incorrect, but in reviewing a possible abuse of discretion.” James v . Louisiana Laborers Health and Welfare Fund, 29 F.3d 1029, 1033 (5th Cir. 1994) (per curiam). The question then is whether the actions Garcia complains of render the defendants’ decision arbitrary and capricious.
-14- or (2) that MetLife should have given more weight to the opinions
of Drs. Rahman and Masi, rather than Dr. Petrie, because they
examined Garcia and D r . Petrie did not.
A. Dr. Rahman’s Opinion
First, as a general matter, a plan administrator is not
required to give controlling weight to the opinion of a treating
physician. See Sheppard & Enoch Pratt Hosp., Inc. v . Travelers
Ins. Co., 32 F.3d 120, 126 (4th Cir. 1994); see also Chandler v .
Raytheon Employees Disability Trust, 53 F. Supp. 2d 8 4 , 91 (D.
Mass. 1999); Greene v . Metropolitan Life Ins. Co., 924 F. Supp.
351, 359-60 (D.R.I. 1996). “To require [a Plan administrator] to
give conclusive weight to the opinion of the treating physician
would deprive it of its role in determining” whether an employee
is disabled. Sheppard & Enoch Pratt Hosp., Inc., 32 F.3d at 126.
Therefore, absent unique circumstances not present here, MetLife
was not required to accord controlling significance to Dr.
Rahman’s opinion. Cf. Doe, 167 F.3d at 58 (affording “special
weight” to treating experts’ diagnosis of suicidal risk because
“[i]t is much harder to calibrate such risks [of suicide] than to
diagnose conditions that can be reduced” to medical test
results).
-15- Regardless of the weight accorded to Dr. Rahman’s opinion,
I note that even he found that Garcia had only “some limitation”
with regard to the following activities: transportation;
standing; sitting; reaching forward or overhead; pushing,
pulling, or twisting; finger dexterity; repetitive movement; and
operating a dolly or small vehicle. Dr. Rahman also found that
Garcia had no limitation with regard t o : change of position
(sitting or standing); bending, stooping, or squatting; or
concentrated visual attention. In addition, D r . Rahman found
that Garcia had no cognitive deficits. These findings arguably
weigh against Dr. Rahman’s ultimate finding of total disability.
At the very least, these findings supported MetLife’s decision to
seek additional evidence of disability.
B. The Opinions of Non-treating Physicians
Second, as a general matter, it is not unreasonable for a
benefit plan administrator to rely on the opinion of a non-
examining physician in reaching an eligibility determination.
See Greene, 924 F. Supp. at 359 (collecting cases). This
principle holds true even where the non-examining physician’s
opinion contradicts that of the examining physician. See id. at
359-60; Chandler, 53 F. Supp. 2d at 9 1 ; see also Doyle, 144 F.3d
-16- at 184 (“Sufficiency, of course, does not disappear merely by
reason of contradictory evidence.”)
In this case, although both Drs. Rahman and Masi examined
Garcia, their opinions contradicted each other. While both of
them diagnosed Garcia with multiple sclerosis, Masi emphasized
that her finding of “totally disabled” was based on her finding
that Garcia suffered from a number of cognitive deficits. Dr.
Rahman, by contrast, never found any such cognitive deficits.
In addition, the private investigator’s surveillance reports
contradict the statements that Garcia made to D r . Masi regarding
his use of a cane for walking. Given this contradictory
evidence, it was not unreasonable for MetLife: (1) not to give
any special weight to the opinions of Drs. Rahman and Masi; and
(2) to ask a non-examining physician to review Garcia’s file.
C. The Record Supports MetLife’s Decision
According to MetLife’s letter to Garcia notifying him of the
termination of his benefits, MetLife’s conclusion that Garcia was
not totally disabled was based upon all the medical and
vocational evidence in the record. Among the evidence in the
record that supports MetLife’s conclusion are the following: (1)
-17- the private investigator’s surveillance report which showed that
Garcia walked without a cane; (2) Dr. Lim’s opinion that Garcia
could work; (3) Dr. Petrie’s opinion that Garcia could work; (4)
the opinion of Dr. Lipchitz, who examined Garcia, that Garcia
could perform sedentary work; and (4) the vocational assessment
report.
The mere presence of a conflict between the opinions of Drs.
Rahman and Masi and the opinions of the other medical and
vocational professionals listed above, does not render MetLife’s
decision arbitrary, capricious, or an abuse of discretion. See
Terry, 145 F.3d at 4 1 ; Doyle, 144 F.3d at 184.
Nor do I find any merit to Garcia’s assertions of bad
faith.6 It is clear that the terms of the Plan placed the burden
on Garcia to show that he was totally disabled. As claims
6 Garcia does not specifically state which particular actions were made in bad faith, but suggests that the defendants’ engaged in a “concerted effort” to terminate his benefits. He implies that the following actions were indicative of bad faith: (1) the defendants’ persistent requests for medical documentation of his disability; (2) the use of a private investigator; and (3) the sending of a telegram, directing him to report to Raytheon for a physical, directly to him instead of to his counsel. He also asserts that Dr. Lipchitz informed him “that the sole reason he was summoned [for the physical] was to be told that his disability benefits were going to be terminated.”
-18- administrator, MetLife has an obligation to ensure the veracity
of claims of disability. With that in mind, and after reviewing
the administrative record, I can infer no bad faith from
MetLife’s conduct. Nor can I infer bad faith from Garcia’s bald
assertion that D r . Lipchitz told him that the sole reason Garcia
was summoned for a physical was to be told that his benefits were
being terminated. Even if Dr. Lipchitz made that statement, it
arguably reflects the fact that Dr. Petrie had recently opined
that Garcia was not totally disabled, rather than evincing a
possible crusade against Garcia. In any event, this statement
alone is not enough to outweigh the substantial evidence in the
record that supports MetLife’s decision.
Although I might have weighed the evidence in this case
differently, I may not substitute my judgment for that of
MetLife. See Terry, 145 F.3d at 4 0 ; Doyle, 144 F.3d at 184.
Given: (1) the numerous medical opinions in the record concluding
that Garcia was not totally disabled; (2) the conflicting nature
of the opinions of Drs. Masi and Rahman; (3) the private
investigator’s surveillance report; and (4) the vocational
assessment report, I conclude that MetLife’s decision was
-19- supported by substantial evidence and reasonable. See Chandler,
53 F. Supp. 2d at 91 (not unreasonable to rely on medical
assessments of examining and non-examining physicians, vocational
assessment report, and surveillance report).
IV. CONCLUSION
After reviewing the administrative record, I find evidence
reasonably sufficient to support MetLife’s conclusion that Garcia
was not “totally disabled” under the Plan. Therefore, the
decision to terminate Garcia’s benefits was neither arbitrary,
nor capricious, nor an abuse of discretion. Accordingly, I deny
plaintiff’s motion for judgment on the administrative record
(doc. n o . 19) and grant defendants’ motion for judgment on the
administrative record (doc. n o . 20) and the clerk is directed to
enter judgment for the defendants.
SO ORDERED.
Paul Barbadoro Chief Judge December 4 , 2000
cc: Fred Forman, Esq. William D. Pandolph, Esq.
-20-