Case Name: Yvonne Fowkes v. Metropolitan Life Insurance Company
Court: U.S. District Court for the Eastern District of California
Date of Decision: January 25, 2017
Insurance Company: Metropolitan Life Insurance Company, aka MetLife
Claimant’s Employer: Vision Service Plan (VSP), an eye care insurance company.
Claimant’s Occupation / Job Position: Ms. Fowkes started work with VSP as a customer service representative and later became a network administrator. Ms. Fowkes’s job as a network administrator included working with providers to ensure compliance with VSP network criteria, evaluating a doctor’s practices to determine if he or she meets VSP criteria, and communicating with doctors and office staff through phone, fax, or email regarding missing VSP network participation criteria information. She was expected to work eight hours a day, mainly in a seated position, while handling “multiple tasks and prioritizing effectively.”
Disabilities: In her claim for STD benefits, Ms. Fowkes attributed her absence to several conditions, including heart disease, shortness of breath, hypoglycemia, and a “full-blown flare-up” of fibromyalgia, which caused her severe pain and confined her to bed rest. In her LTD claim, Ms. Fowkes stated she could not work because of fibromyalgia, chronic epileptic seizures, frequent chest pain, dizziness, issues with her coronary artery, and an inability to walk due to her knee-replacement surgeries.
Definition of Disability in the Plan/Policy: The Certificate of Insurance Plan provided its definition of “disability” as follows:
“Disability or Disabled means that as a result of Sickness or injury You are [either] Totally Disabled [or Partially Disabled].
Totally Disabled or Total Disability means:
During the Elimination Period and the next 24 months, You are unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue Your Usual Occupation in the usual and customary way.
After such period, You are not able to engage with reasonable continuity in any occupation in which You could reasonably be expected to perform satisfactorily in light of Your:
- station in life; and
- physical and mental capacity
that exists within any of the following locations:
- a reasonable distance or travel time from Your residence in light of the commuting practices of Your community;
- a distance of travel time equivalent to the distance or travel time You traveled to work before becoming disabled; or
- the regional labor market, if You reside or resided prior to becoming disabled in a metropolitan area.”
(brackets in original)
Other Key Definitions in the Plan/Policy: “Substantial and material acts,” also discussed in the disability provision, are defined as follows:
“the important tasks, functions and operations generally required by employers from those engaged in Your Usual Occupation that cannot be reasonably omitted or modified.
In determining what substantial and material acts are necessary to pursue Your Usual Occupation, We will first look at the specific duties required by Your job.
If You are unable to perform one or more of these duties with reasonable continuity, We will then determine whether those duties are customarily required of other employees engaged in Your Usual Occupation.”
“Usual occupation” is similarly discussed in the disability provision, and is defined in part as:
“any employment, business, trade or profession and the Substantial and Material Acts of the occupation You were regularly performing for the employer when the Disability began. Usual Occupation is not necessarily limited to the specific job that You performed for the employer.”
The Plan also summarizes how an employee can support her disability claim:
“If You become Disabled while insured, Proof of Disability must be sent to Us. When We receive such Proof, We will review the claim.”
“Proof” is defined as follows:
“Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish:
- the nature and extent of the loss or condition;
- Our obligation to pay the claim; and
- the claimant’s right to receive payment.”
MetLife’s Evaluation of the Medical Evidence: Based on nurse consultant Manley’s findings, MetLife concluded Ms. Fowkes did not have enough evidence “demonstrating the functional impairments provided that would support [Ms. Fowkes’s] inability to perform her sedentary job duties.”
On December 13, 2013, MetLife sent an LTD claim status letter to Ms. Fowkes, discussing the information needed to support her claim: “The information needed includes office visit notes, diagnostic test reports, therapy notes and evaluations, procedure reports, hospital admission and discharge summaries, and other medical information which will support your claim for disability.”
Ms. Fowkes sent MetLife office notes, medical diagnoses, and lab reports. However, a new nurse consultant concluded there were no notes from Ms. Fowkes’s cardiologist, rheumatologist, or neurologist to support a finding of disability due to cardiac issues, fibromyalgia, or epilepsy.
MetLife denied Ms. Fowkes’s LTD claim.
Basis For Denial of Appeal: MetLife informed Ms. Fowkes and her attorney of the denial by letter to her attorney, which stated in part: “Our review, which included a Board Certified [Independent Physician Consultant], who spoke with Ms. Fowkes’s treating providers, found there was insufficient clinical evidence to support a severity of Ms. Fowkes’s medical conditions that would support a continuous impairment or would prevent Ms. Fowkes from performing her own job, or usual occupation from March 12, 2013 forward.”
Procedural history: Ms. Fowkes, through her attorney, appealed MetLife’s LTD claim denial. With Ms. Fowkes’s lawyer, MetLife confirmed her position that the following conditions impacted her functioning: (1) osteoarthritis, (2) congenital heart failure, (3) epilepsy with resulting seizures, (4) right-hand tremors, and (5) fibromyalgia.
On October 16, 2014, Ms. Fowkes’s attorney responded to MetLife’s second denial letter with additional records to support Ms. Fowkes’s disability claim. He faxed a complete medical report from social worker Maatisak Amenhetep, which evaluated Ms. Fowkes’s mental and emotional capabilities.
While the record does not make clear whether supporting evidence was submitted, Ms. Fowkes also contends that on February 24, 2015, the Social Security Administration (SSA) found her to be disabled with an onset date of March 12, 2013.
Key Physician Opinions: In support of her appeal, Ms. Fowkes provided a letter from Dr. Oh dated March 31, 2014, and a letter from Dr. Bukkapatnum dated April 3, 2014. In his letter, Dr. Oh reported Ms. Fowkes had been treated within the UC Davis Health System for the last six years because of her seizures. He noted it was uncertain whether the “origin of the seizures is epileptic or non-epileptic . . . and further diagnostic studies are planned.” No laboratory or medical tests were attached to the letter.
The letter from Dr. Bukkapatnum stated Ms. Fowkes was under his care for complex cardiovascular issues. In the letter, Dr. Bukkapatnum stated Ms. Fowkes has “severe diastolic dysfunction, orthostatic hypotension, [and] sick sinus syndrome with a pacemaker.” As with Dr. Oh’s letter, Dr. Bukkapatnum did not attach laboratory or medical test results.
MetLife next sent Ms. Fowkes’s file to Dr. Arousiak Varpetian, a board-certified neurologist and independent physician consultant for an independent third-party review. MetLife asked Dr. Varpetian if the physical conditions “alone, or in combination, support [Ms. Fowkes’s disability claim].” MetLife also asked Dr. Varpetian to describe the clinical findings that supported Ms. Fowkes’s functional limitations. Id. Dr. Varpetian reviewed Ms. Fowkes’s appeal file, including notes, labs, and reports from her doctor’s visits from 2010 to 2014, and concluded “the documentation does not support continuous functional impairment.”
Issues: The court addresses the standard of review governing the ERISA cross-claims, the propriety of considering evidence submitted after MetLife’s appeal denial, and the merits of the parties’ cross-claims. As explained in more detail below, the court reviews the cross-claims under a de novo standard, does not consider documents submitted after MetLife’s appeal denial, and concludes Ms. Fowkes has not established disability under the terms of the Plan.
Holdings: (1) On January 1, 2012, California barred the application of language in an employment insurance plan that grants discretionary authority to the plan administrator.
Here, the certificate date of MetLife’s insurance Plan is January 1, 2011. This same policy was in effect in October 2014, when MetLife denied Ms. Fowkes’s long term disability benefits. The policy “thus continued in force on or after the policy’s anniversary date.” See id.; Cal. Ins. Code § 10110.6. Section 10110.6 applies here and voids any grant of discretion to the Plan administrator. Accordingly, the de novo standard is proper.
(2) Where, as here, the court reviews an ERISA claim de novo, it can admit outside evidence “only when circumstances clearly establish that additional evidence is necessary to conduct an adequate de novo review of the benefit decision.” Mongeluzo v. Baxter Travenol Long Term Disability Benefit Plan, 46 F.3d 938, 944 (9th Cir. 1995) (citation omitted). In most cases where review is de novo, “additional evidence is not necessary for adequate review of the benefits decision, [and] the district court should only look at the evidence that was before the plan administrator . . . at the time of the determination.” Id. That “someone at a later time comes up with new evidence” does not make outside review necessary. Id. Rather, the facts of the case should fit within one of the following non-exhaustive “list of exceptional circumstances” to warrant consideration of materials beyond the record: claims that require consideration of complex medical questions or issues regarding the credibility of medical experts;  the availability of very limited administrative review procedures with little or no evidentiary record;  the necessity of evidence regarding interpretation of the terms of the plan rather than specific historical facts;  instances where the payor and the administrator are the same entity and the court is concerned about impartiality;  claims which would have been insurance contract claims prior to ERISA; and  circumstances in which there is [sic] additional evidence that the claimant could not have presented in the administrative process.
Opeta v. Nw. Airlines Pension Plan, 484 F.3d 1211, 1217 (9th Cir. 2007) (citation omitted).
Here, the Social Security decision is not necessary or relevant to the court’s de novo review. First, while no Ninth Circuit holding explicitly speaks to the issue of whether a subsequently granted SSA award should be considered, the Seventh Circuit has addressed the question, persuasively. In Majeski v. Metro. Life Ins. Co., 590 F.3d 478, 483 (7th Cir. 2009), that circuit opined a district court need not consider a subsequently granted SSA award in evaluating a plan administrator’s decision, because doing so would pose “practical problems” by effectively allowing supplementation of the administrative record “without limit,” and would amount to reopening a “closed appeal” to consider evidence not before the administrator at the time of review. Id.
Second, while Ms. Fowkes’s case is analogous to Mongeluzo in that the SSA disability finding became available only after MetLife denied her LTD claim, her case is distinguishable in that the “new evidence” is unnecessary for a full review because the definitions of disability under the Plan and SSA rules are different.
Finally, unlike in Mongeluzo, Ms. Fowkes does not contend MetLife’s Plan is ambiguous, or that MetLife erroneously defined a term in the Plan. Ms. Fowkes merely argues that under the terms of the Plan, she qualifies for LTD benefits. The SSA award will not be considered in reviewing the merits of Ms. Fowkes’s ERISA claim.
(3) Where a plan requires a claimant to provide “satisfactory proof” of disability, the claimant must proffer evidence not only that she has a relevant diagnosis, but also that the illness or injury precludes her from performing the tasks required by her regular occupation. See Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004) (“That a person has a true medical diagnosis does not by itself establish disability”), overruled in part on other grounds by Abatie, 458 F.3d at 969.
Ms. Fowkes does not contend the Plan’s written evidence requirement violates ERISA. Instead, she takes issue with the procedures MetLife used to evaluate her LTD claim. In particular, she contends MetLife required her to present “objective evidence” in support of her LTD claim, id., and argued at hearing that MetLife did not consider the cumulative effect of her conditions in determining whether she adequately established disability. MetLife contends subjective reports of pain need not be taken at face value and argued at hearing no disability is established even when considering Ms. Fowkes’s conditions in combination.
Even assuming Ms. Fowkes’s contentions have merit, they do not warrant judgment in Ms. Fowkes’s favor at this late stage, for she does not point the court to the “written proof” needed to establish disability under the terms of the Plan. This lack of written proof provides sufficient grounds to uphold MetLife’s decision to deny LTD benefits.
Summary: In sum, upon de novo review, Ms. Fowkes has not met her burden to establish she was disabled under the terms of the Plan.