Ortiz Torres v. Metropolitan Life Insurance

555 F. Supp. 2d 281, 2007 WL 5159650
District Court, D. Puerto Rico·Decided July 19, 2007·No. Civil 04-1967 (FAB)·Published

Opinion

OPINION AND ORDER

BESOSA, District Judge.

Before the Court is plaintiffs’ motion for judgment on the administrative record (Docket No. 28), and defendant’s opposition and cross-motion for judgment on the administrative record (Docket No. 32). For the reasons, discussed below, the Court GRANTS defendant’s cross-motion and dismisses plaintiffs complaint.

FACTUAL BACKGROUND

Emma Ortiz (“Ortiz”) worked for Scher-ing-Plough Corporation (“Schering”) since March 21, 1988. Her last position at Schering was pharmaceutical operator. While working at Schering, Ortiz was a participant of a long-term disability (“LTD”) plan (the “plan”) administered by Metropolitan Life Insurance Company (“MetLife”). The plan provides that Met-Life, as plan administrator, would have discretionary authority to interpret the *282 terms of the plan and to determine eligibility for and entitlement to plan benefits.

The plan provides for the payment of LTD benefits to a participant who becomes disabled. A participant is considered “disabled” when due to an injury or sickness, the participant requires the regular care and attendance of a physician and is unable to perform each of the material duties of his or her regular job. After the first twenty-four months of benefit payments, the participant must also be unable to perform each of the material duties of any gainful work or service for which he or she is reasonably qualified, taking into consideration training, education, experience, and past earnings.

Ortiz last worked for Schering on March 23, 1990. On September 26, 1990, Ortiz submitted a claim for LTD benefits under the plan. Ortiz’s claim was based on her physician’s diagnosis of eervieo thoraeo lumbrosacral myositis. On October 26, 1990, MetLife sent notice to Ortiz that her claim had been approved. On July 16, 1991, Dr. Hector Cases (“Dr.Cases”), a neurologist retained by MetLife, conducted an independent medical examination of Ortiz. Dr. Cases reported that although Ortiz suffered from a chronic moderate cervical myositis, chronic mild dorsal spasm and a chronic moderate LS myosi-tis, she was still able to perform part time sedentary work.

On June 4, 1992, MetLife retained Crawford & Company (“Crawford”) to conduct an independent vocational assessment of Ortiz. On June 29, 1992, Crawford submitted a report concluding that Ortiz retained sufficient transferable skills within her residual functional capacity to perform light duty work with salaries commensurate with her previous earnings and that she was not totally disabled according to the plan’s definition. Nevertheless, MetLife continued to pay LTD benefits to Ortiz.

On October 6, 1997, Ortiz underwent a functional capacity assessment by Dr. Rafael Sein (“Dr.Sein”) at MetLife’s request. Dr. Sein determined that Ortiz had a work capacity of sedentary level and that her physical condition could improve through a Work Conditioning/Work Hardening program.

On September 13, 2000, MetLife referred Ortiz’s medical records to Dr. Jeffrey Kahn (“Kahn”) for an independent medical evaluation. Dr. Kahn reported that the medical evidence he reviewed showed degenerative anterior spondylosis and straightening of normal lumbar lordosis, but that the cervical changes would not affect Ortiz’s neurological function and that the lumbar x-rays were normal. Dr. Kahn concluded that the medical test results in the administrative record did not support the level of work capacity listed by the attending physician on the most recent physical capacities evaluation, which he thought exaggerated the degree of functional limitations. Dr. Kahn further stated that he did not know why Ortiz’s benefits had not been terminated or why she was not given vocational training or a different job placement after the 1992 transferable skills analysis and the 1997 functional capacity evaluation.

MetLife did not terminate Ortiz’s benefits upon receiving Dr. Kahn’s report, but continued to request information from Ortiz and her attending physicians in order to evaluate her condition fully. This included a statement from Dr. Jose Camino (“Camino”), which indicated Ortiz had been under his care since 1991 and that she had been completely disabled and unable to do housework, much less any gainful employment, since May 1990. Dr. Camino further stated that Ortiz suffered from fibromyalgia, major depression with *283 panic disorder, radiculopathy, lumbar spondilosis, calcified tendonitis and moderate arterial hypertension. The statement did not include any objective medical data to support the diagnosis.

In October 2002, MetLife retained the services of Dr. John D. Thomas (“Thomas”), to conduct another independent medical evaluation of Ortiz’s condition. On October 29, 2002, Dr. Thomas issued a report stating that he had reviewed Dr. Kahn’s report and the medical evidence obtained thereafter and that he could not find evidence to support a severe impairment that would completely preclude Ortiz from performing sedentary work.

On January 23, 2003, MetLife notified Ortiz by letter that she was no longer considered disabled under the plan and was no longer entitled to disability benefits. MetLife indicated that it would terminate her benefits effective February 1, 2003. On February 19, 2003, MetLife received a letter from Ortiz appealing the decision to terminate her LTD benefits and submitting new medical evidence from her doctors. After MetLife received the new evidence, it referred it to Dr. Warren Silverman (“Silverman”) for an independent evaluation. Dr. Silverman concluded that there was no evidence to alter the findings made by Drs. Kahn and Thomas that Ortiz was able to perform sedentary work. On June 20, 2003, MetLife sent Ortiz a letter upholding the decision to terminate her LTD benefits.

DISCUSSION

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