United States District Court, N.D. Oklahoma
OPINION AND ORDER
JOHN
E. DOWDELL, CHIEF JUDGE UNITED STATES DISTRICT COURT.
Plaintiff,
Patricia Ann McNeal, brings this action pursuant to the
Employee Retirement Income Security Act of 1974, as amended
(ERISA), 29 U.S.C. § 1001 et seq., to recover
benefits under an employee benefit plan, and to recover costs
and attorney's fees as provided by ERISA. McNeal claims
that the defendant, Metropolitan Life Insurance Company
(MetLife), improperly denied her long-term disability
benefits.
I.
Background
Employment
as a Clinician
The
following facts are undisputed by record evidence, except
where noted. McNeal began working for Alternative
Opportunities, Inc. (Alternative) at its DaySpring Behavioral
Health Services location in Tulsa, Oklahoma in October 2008.
In January 2014, she fell and injured her left knee. At the
time of McNeal's knee injury, she was a Master's
Degree Clinician. (Administrative Record [AR]
0538).[1] Alternative's job description
summarizes McNeal's occupation as “[p]rovid[ing]
clinical services for the improvement and psychological
functioning of persons served.” (AR 0547). The
“Essential Duties and Responsibilities” of her
job included “[p]rovid[ing] professional clinical
services to AO DaySpring participants [sic] clients including
assessment, referral, treatment planning, counseling, and
discharge planning, [c]omplet[ing] all clinical and
administrative documentation, . . . [a]ttend[ing]
professional staffing, ” and other duties.
(Id.).
Disability
Coverage
Alternative
provided short-term disability (STD) and long-term disability
(LTD) insurance coverage to its eligible employees. (AR 0538,
0437-49). Pursuant to the group LTD insurance policy (the
Plan), claims for LTD benefits were administered, and
benefits due under the Plan were paid, by MetLife.
(See AR 0599). Alternative was the Employer and Plan
Administrator as defined under the Plan. Under the Plan,
“disabled” or “disability” were
defined as follows:
Disabled or Disability
means that, due to Sickness or as a direct result of
accidental injury:
. You are receiving Appropriate Care and
Treatment determined by Your Physician as necessary to treat
the Sickness or injury;
. Complying with the requirements of such
treatment; and
. You are unable to earn:
. during the first 24 months of Sickness or
accidental injury, more than 80% of Your Predisability
Earnings at Your Own Occupation for any employer in Your
Local Economy; and
. after such period, more than 80% of your
Predisability Earnings from any employer in Your Local
Economy at any gainful occupation for which You are
reasonably qualified taking into account Your training,
education and experience.
(AR 0569, 0628). “Own Occupation” is defined by
the Plan as “the essential functions You regularly
perform that provide Your primary source of earned
income.” (AR 0570, 0629).
According
to the policy, MetLife must receive Proof of Disability in
order to review and approve a LTD claim. (AR 0578, 0637). As
defined in the policy, “Proof means Written evidence
satisfactory to [MetLife] that a person has satisfied the
conditions and requirements for any benefit described in this
certificate, ” and “[w]hen a claim is made for
any benefit . . ., Proof must establish:
. the nature and extent of the loss or
condition;
. [MetLife's] obligation to pay the
claim; and
. the claimant's right to receive
payment.”
(AR 0572).
STD
Benefits
On
February 27, 2014, McNeal underwent a total left knee
arthroplasty. She applied for STD benefits under the MetLife
policy. MetLife found it reasonable that McNeal was unable to
perform any of her job functions while recovering from knee
replacement surgery. (AR 0007-10). MetLife notified McNeal
that her short-term benefits had been approved for the 8-week
period of February 27, 2014 through April 23, 2014, and
informed her that additional medical information would be
necessary for MetLife to consider benefits beyond April 23.
(AR 0007, 0530-34).
On
April 18, 2014, MetLife received a Supplementary Attending
Physician Statement (SAP) from Ryan Gursky, D.O., reporting
that McNeal's diagnosis was left knee degenerative joint
disease, she was prescribed Percocet and Norco, and
indicating that plaintiff would be “continuously unable
to perform required job duties from 02-27-14 - May 22,
2014.” (AR 0527). Dr. Gursky noted that McNeal was at
that time “unable to bend, squat, lift, stand, [or]
twist.” (Id.). McNeal's treatment plan was
to continue physical therapy and “follow up in office
4-28-14.” (Id.). On April 22, 2014, MetLife
notified McNeal that her STD benefits had been extended
through May 22, 2014. (AR 0013, 0519).
Additional
information from Dr. Gursky, dated May 15, 2015, indicated
that plaintiff had the following “restrictions to work
or activity”: “Patient still recovering from
surgery; and working on strength & mobility; unable to
squat, bend, kneel.” (AR 0517). McNeal's physician
did not explain why the inability to squat, bend, or kneel
would prevent her from performing her counseling duties.
On May
21, 2014, a MetLife STD claim specialist explained to McNeal
that, in view of her light job and the normal recovery time
for knee replacement surgery, in order to extend her STD
benefits, MetLife required detailed medical reasoning,
restrictions, and limitations relevant to McNeal's
functional job requirements. (AR 0018). On May 22, MetLife
wrote to Dr. Gursky:
This letter is in regard to your patient, Patricia
McNeal's Short Term Disability claim. We recently
received an Attending Physician's Statement form from you
that was not completely filled out. Ms. McNeal had Total Knee
Replacement on 2/27, and has now had 12 weeks to recover. In
order for the claim to be extended further we need to know
what current restrictions are preventing Ms. McNeal from
being able to perform the physical duties of her job as a
Clinician, which are defined by her employer below:
“While performing the duties of this job, the employee
is regularly required to talk and hear. The employee
frequently is required to use hands to finger, handle or
feel. The employee is occasionally required to stand, walk,
and sit. The employee must occasionally list [sic] and/or
move up to 10 pounds. Specific vision abilities required by
this job include close vision, and ability to adjust
focus.”
We will also need to know the current treatment plan
that is in place to address those restrictions/limitations,
if there are any accommodations that can be made to assist
the patient in returning to work, and an estimated date that
the patient will be able to return to work without
restrictions or the ...