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Osobka v. Metropolitan Life Insurance Co.

United States District Court, E.D. Michigan, Southern Division

August 25, 2017




         I. Introduction

         Plaintiff Kristina Osobka challenges Defendant Metropolitan Life Insurance Company's ("MetLife's") denial of her long-term disability benefits application. Plaintiff is a former Comcast Corporation ("Comcast") customer service representative who contends she suffered from chronic fatigue syndrome ("CFS") and was unable to work. She filed for benefits under Comcast's long-term disability plan, which Defendant administered. After Defendant denied both her initial application and her appeal, Plaintiff filed this lawsuit under the Employee Retirement Income Security Act ("ERISA"), 29U.S.C. § 1132(a)(1)(B).

         Before the Court are two motions: (1) Plaintiffs motion to reverse Defendant's denial of her long-term disability (LTD) benefits application, and (2) Defendant's cross-motion to affirm its denial. The dispositive question is whether Defendant abused its discretion in crediting the opinions of independent physician consultants rather than those of Plaintiffs treating physicians. For the reasons outlined below, the Court finds that Defendant was within its discretion in denying Plaintiffs application for long-term disability benefits. Therefore, Plaintiffs motion to reverse Defendant's decision must be DENIED, and Defendant's motion to affirm must be GRANTED.

         II. Background

         Plaintiff worked for Comcast as a customer service representative from June 23, 2013 until August 6, 2014. At Comcast, she participated in the Comprehensive Health and Welfare Benefit Plan ("the Plan"), a long term disability policy that Defendant provided and administered.

         Defendant makes initial eligibility determinations on claims for disability benefits under the Plan. If denied, employees may appeal to Defendant for further review of their claim. Plaintiff claimed she suffered from various viral infections, which caused chronic fatigue syndrome (CFS), rendered her disabled, and forced her to take leave from her job at Comcast on August 6, 2014. On July 13, 2015, Defendant denied Plaintiffs initial application for LTD benefits and on May 25, 2016, Defendant denied Plaintiffs appeal.

         1. MetLife's LTD Plan

         The Plan defines "disability" as the inability to earn more than eighty percent of prior earnings in one's occupation due to sickness or injury. Dkt. 6-1, Pg. ID 47. To qualify for LTD benefits, a claimant must first continuously meet this definition for 180 days (the "Elimination Period"). Dkt. 6-1, Pg. ID 47. Plaintiff stopped working at Comcast on August 7, 2014. Thus in order to qualify for LTD benefits she must have been disabled from August 7, 2014, to February 8, 2015. Dkt. 6-5, Pg. ID 354.

         The Plan also excludes pre-existing conditions from LTD coverage if the claimant has not been "Actively at Work" for 12 months. Dkt. 10-2, Pg. ID 2056. Pre-existing conditions are defined as any "sickness or accidental injury" for which a claimant received care, or experienced symptoms "that would cause a person to seek diagnosis, care or treatment, " in the 3 months before claimant's coverage took effect. Dkt. 10-2, Pg. ID 2056.

         The Summary Plan Description, a document that explains a claimant's rights and obligations under the Plan, designates Defendant as the Plan administrator and delegates to Defendant the "sole discretion to interpret plan provisions and to determine questions of fact and eligibility for benefits." Dkt. 6-3, Pg. ID 145.

         2. Initial Denial of LTD Benefits

         As a Comcast customer service representative, Plaintiff worked at a desk and communicated with clients who were dissatisfied with Comcast's telecommunications services. Dkt. 7-6, Pg. ID 1786. Claiming she could no longer perform these tasks, Plaintiff took leave from Comcast beginning on August 7, 2014. Dkt. 6-6, Pg. ID 362. Plaintiff then applied for LTD benefits with Defendant. Dkt.7-5, Pg. ID 1636-52. Additionally, Plaintiff applied for and was denied Social Security Disability Insurance Benefits. Dkt. 7-6, Pg. ID 1774.

         As part of its LTD benefit determination, Defendant requested medical records from Plaintiffs treating physicians. Dkt. 7-2, Pg. ID 1287-88, 1292-93; Dkt. 7-5, Pg. ID 1603-32. Dr. Brian Massa-ro's records indicate that Plaintiff was diagnosed with anxiety in or prior to 2011 and chronic fevers and fatigue since November 2013. Dkt. 6-6, Pg. ID 453. Plaintiff visited CFS specialist Dr. Martin Lerner on September 29, 2014. Dkt. 6-6, Pg. ID 496. Dr. Lerner's October 21, 2014, report informed Defendant that Plaintiff was unable to ...

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