Vega-Muñiz v. Metropolitan Life Insurance

278 F. Supp. 2d 146, 31 Employee Benefits Cas. (BNA) 1976, 2003 U.S. Dist. LEXIS 14192, 2003 WL 21939482
CourtDistrict Court, D. Puerto Rico
DecidedJuly 31, 2003
DocketCIV. 02-1117(JP)
StatusPublished

This text of 278 F. Supp. 2d 146 (Vega-Muñiz v. Metropolitan Life Insurance) is published on Counsel Stack Legal Research, covering District Court, D. Puerto Rico primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Vega-Muñiz v. Metropolitan Life Insurance, 278 F. Supp. 2d 146, 31 Employee Benefits Cas. (BNA) 1976, 2003 U.S. Dist. LEXIS 14192, 2003 WL 21939482 (prd 2003).

Opinion

OPINION AND ORDER

PIERAS, Senior District Judge.

I. INTRODUCTION

The Court has before it Defendants’ Motion for Summary Judgment (docket No. 30), Plaintiffs Opposition to Defendants’ Motion for Summary Judgment and Cross Motion for Summary Judgment (docket No. 33), Defendants’ opposition thereto (docket No. 39), and Defendants’ Supplement to Motion for Summary Judgment and Opposition to Plaintiffs Cross-Motion for Summary Judgment (docket No. 41). Plaintiff was formerly employed by Defendants Abbott Laboratories and Abbot Health Products. He was a beneficiary under a Group Long Term Disability (“LTD”) benefit policy issued by Metropolitan Life Insurance Company (“Metlife”) through his former employer.

Plaintiff brings this action pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461, for wrongful denial of benefits under ERISA and breach of fiduciary duty against Defendant Metlife. Plaintiff was covered by a benefits policy administered by Metlife as an employee at Abbott Health Products of Puerto Rico (“Abbott”). Plaintiff claims that he suffered from “Frontal Lobe Syndrome”, an organic condition in the brain that results in mental disorders.

Defendant now move for summary judgment, alleging that, under the plan, Plaintiffs medical condition, which they found to be psychological, was only subject to coverage for a twenty-four month period. Defendants state that their termination of his benefits after that period ended was proper and was not arbitrary and/or capricious based on the standard set forth by ERISA.

II. UNCONTESTED FACTS

The following facts are adapted from the uncontested facts as described in Plaintiffs Opposition (docket No. 33) and Defendants’ Statement of Uncontested Material Facts. The parties have no disputes of material facts in this case.

1. Plaintiff Carlos Vega Muñiz was employed by Abbott in a manufacturing facility located in Barceloneta, Puerto Rico, for over twenty-three years.

2. Metlife is a corporation organized and existing under the laws of the State of New York with its principal place of business in New York, and is licensed to issue a contract of insurance in the Commonwealth of Puerto Rico.

*148 3. Metlife issued the group Long Term Disability Plan (the “Plan”) at issue in this litigation.

4. Abbott is Plaintiffs former employer and the party who established the Plan.

5. Abbott established and maintained a Plan for its employees for the purpose of providing benefits in the event of long-term disability.

6. The Plan is governed by ERISA.

7. Metlife has the responsibility of claim fiduciary for the provision of full and fair review of claim denials, pursuant to Section 503 of ERISA, 29 U.S.C. § 1133.

8. Pursuant to the Plan, “Disability” or “Disabled” means that, due to an injury or sickness, [claimant] require[s] the regular care and attendance of a doctor and:

1. [claimant is] unable to perform each of the material duties of [claimant’s] regular job; and
2. after the first 24 months of benefit payments, [claimant] must also be unable to perform each of the material duties of any gainful work or service for which [claimant is] reasonably qualified taking into consideration [claimant’s] training, education, experience and past earnings;

9. In its exclusions, the Plan provides the following “Mental Illness Limitation”:

While you are Disabled due to a Mental Illness and not confined in a hospital or institution, the Monthly Benefit will be payable up to lesser of:
1. 24 months; or
2. The Maximum Benefit Duration on the SCHEDULE OF BENEFITS.

10. The Plan defines “Mental Illness” as a “mental, emotional, or nervous condition of any kind.”

11. Plaintiff began ambulatory psychiatric treatment with Dr. J.A. Mojica Sandoz in 1995, based on complaints of depressive episodes.

12. Plaintiff underwent treatment with Dr. Elias Jiménez in August 1996, also based on complaints of depressive episodes.

13. Plaintiff initially left his position at Abbott in May 1997.

14. Plaintiff returned briefly, then left permanently on October 31,1997.

15. Plaintiff initially requested LTD Benefits from Metlife on December 19,1997.

16. Plaintiff began to receive benefits effective January 1,1998.

17. On June 10, 1999, Plaintiff sent Metlife the latest information from Dr. Elias Jiménez Olivo and Dr. Miguel Licha stating that his emotional condition was caused by an organic anomaly in his brain. The record from Dr. Jiménez Olivo’s office included the last visit, dated May 24, 1999.

18. On July 7, 1999, Metlife’s staff psychiatrist Dr. Ian Lipsitch issued an update to the diary entering date June 16, 1999, in which he stated: This is a 52 year old man with a several year history of a major Depressive disorder, recurrent type and “cyclothymic personality” He has been treated with an antidepressant (ser-zone) and mood stabilizer (... ium) but continued to be sufficiently impaired that he was awarded Soc. Sec. Disab. At this point, he is alleging that he is suffering from a physical illness since the doctors have told him that there were no environmental or external issues driving his depression. I have reviewed the file, much of *149 which is in Spanish. However, there is no indication of a neurological illness or other physical illness driving his disability. Major depression and Cyclothymia are considered to be mental and nervous rather than physical disorder, even though there may be genetic or other physical factors involved. They are generally thought to be psychiatric conditions and the limitation of the policy are meant to include such illnesses. There is nothing extraordinary about this case in that context. 1

19. Metlife asked its Staff Psychiatrist, Dr. Lipsitch, to review the new medical information it received.

20. Metlife also sought review from an independent psychiatrist, Dr. Luis E. Canepa.

21. On July 14, 1999, Dr. Lipsitch reported the following regarding to the additional information provided by Plaintiff to Metlife:

This claim was recently reviewed by this reviewer and my comment is that the diagnosis which have been offered by the AP, namely Bipolar D/O and major depressive disorder, are typically thought of as psychiatric disorders, i.e. mental and nervous disorders, regardless of etiology, be it biologic or functional.

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Bluebook (online)
278 F. Supp. 2d 146, 31 Employee Benefits Cas. (BNA) 1976, 2003 U.S. Dist. LEXIS 14192, 2003 WL 21939482, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vega-muniz-v-metropolitan-life-insurance-prd-2003.