McNeal v. Metropolitan Life Insurance Company

          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 ...