Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-5_04-cv-01108/USCOURTS-alnd-5_04-cv-01108-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 28:1441eri - Petition for removal - E.R.I.S.A.

---

1 Plaintiff originally filed suit in the Circuit Court of Jackson County, Alabama, and

defendant timely removed the action to this court on May 28, 2004. See doc. no. 1 (Notice of

Removal). 

2

See Complaint, appended to doc. no. 1 (Notice of Removal).

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ALABAMA

NORTHEASTERN DIVISION

SUZANNE WILLMON, )

)

Plaintiff, )

)

vs. ) Civil Action No. CV-04-S-1108-NE

)

METROPOLITAN LIFE )

INSURANCE COMPANY, )

)

Defendant. )

MEMORANDUM OPINION

Plaintiff, Suzanne Willmon, a former employee of Peoples State Bancshares,

Inc., filed this action under sections 1132(a)(1)(B) and (a)(3) of the Employee

Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq.1

Plaintiff also asserted supplemental state law claims for breach of contract and bad

faith failure to pay insurance benefits. 

Plaintiff claims she was wrongfully denied long-term disability benefits

pursuant to her employer’s group, long-term, disability insurance policy.2

 The policy

was underwritten by defendant, Metropolitan Life Insurance Company (“Met Life”

or “defendant”). The action now is before the court on defendant’s motion for

FILED

 2005 Nov-28 AM 11:23

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 1 of 26
3

 Doc. no. 8.

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summary judgment.3

 Upon consideration of the pleadings, evidentiary submissions,

and briefs, the court concludes the motion should be granted. 

Federal Rule of Civil Procedure 56(c) provides, in part, that summaryjudgment

“shall be rendered forthwith if the pleadings, depositions, answers to interrogatories,

and admissions on file, together with the affidavits, if any, show that there is no

genuine issue as to any material fact and that the moving party is entitled to judgment

as a matter of law.” Fed. R. Civ. P. 56(c). Thus, “the plain language of Rule 56(c)

mandates the entry of summary judgment, after adequate time for discovery and upon

motion, against a party who fails to make a showing sufficient to establish the

existence of an element essential to that party’s case, and on which that party will

bear the burden of proof at trial.” Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986).

In making this determination, the court must review all evidence and

make all reasonable inferences in favor of the party opposing summary

judgment.

The mere existence of some factual dispute will not defeat

summary judgment unless that factual dispute is material to an issue

affecting the outcome of the case. The relevant rules of substantive law

dictate the materiality of a disputed fact. A genuine issue of material

fact does not exist unless there is sufficient evidence favoring the

nonmoving party for a reasonable jury to return a verdict in its favor.

Chapman v. AI Transport, 229 F.3d 1012, 1023 (11th Cir. 2000) (en banc) (quoting

Haves v. City of Miami, 52 F.3d 918, 921 (11th Cir. 1995)); see also United States v.

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 2 of 26
4 The Initial Order, Appendix II, provides the following with respect to responses to the

statement of facts in a moving party’s motion for summary judgment: 

The first section must consist of only a response to the moving party’s

claimed undisputed facts, and shall contain a specific response to each numbered

sentence in the movant’s list of claimed undisputed facts. The response must consist

of the word “Admitted,” or the word “Disputed,” or a short explanatory phrase such

as “Admitted but not material,” or “Admitted but context clarified in brief.” Any

statements of fact that are disputed by the non-moving party must be followed by a

specific reference to those portions of the evidentiary record upon which the

disputation is based. All material facts set forth in the statement required of the

moving party will be deemed to be admitted for summary judgment purposes unless

controverted by the response of the party opposing summary judgment.

Doc. no. 4 (Initial Order Governing All Further Proceedings), Appendix II, at iii-iv (emphasis in

original). Plaintiff did not attempt to controvert defendant’s statement of facts as required by the

Initial Order. Accordingly, defendant’s statement of facts are deemed admitted for summary

judgment purposes. Likewise, those facts which were set forth by plaintiff in her brief, but were not

disputed by defendant in its reply brief, will be deemed admitted. See id. at iv-v.

5

See defendant’s evidentiary submission, appended to doc. no. 8, Tab 1 (Affidavit of Laura

Sullivan), Exhibit B (Claim File), at document bearing Bates Stamp No. Met Life 00346.

6

See id. at document bearing Bates Stamp No. Met Life 00337. Plaintiff listed the following

specific duties encompassed by her job: i.e., 

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Four Parcels of Real Property, 941 F.2d 1428, 1437 (11th Cir. 1991) (en banc). 

I. SUMMARY OF FACTS4

A. Plaintiff’s Employment With Peoples State Bancshares, Inc.

Plaintiff Suzanne Willmon was employed by Peoples State Bancshares, Inc.

(“Peoples”), in various capacities from 1983 until 1996.5 Her last position, Assistant

Vice-President, primarily required her to perform marketing and public relations

duties, including coordinating publications in local media, public speaking, keeping

in touch with customers, and coordinating events.6 

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 3 of 26
1. Public Relations story in Newspaper about Peoples State Bank once a week.

2. Speak to a class at the School (Grammer [sic], Middle & High School) on

Banking once a week.

3. Send Birthday Cards to New Customers.

4. Send flowers to Funerals of people in the Community.

5. Send Get Well Cards to Customers who are known to be sick or in the

Hospital.

6. Watch for Birth Announcements in the paper and send letters to all New

Parents from Peoples State Bank.

7. Attend all Grand Openings of New Businesses in the Market area, and send

flowers to that Business from the Bank.

8. Set up Refreshments for Customer Appreciation Day once a month in the

Bank lobby.

9. Sponsor Student Of The Month at the School — present Student with a

$50.00 Savings Bond.

10. Sponsor and Coordinate a Career Day at the High School once a year.

11. Volunteer to help raise money for all the local charities.

12. Develope [sic] and Coordinate a New Account Contest for all Employees of

Peoples State Bank to participate in — with Cash Prizes.

13. Develope [sic] and Coordinate an Essay Contest for Students on various

subjects — give Savings Bonds to top (3) Students sponsored by Peoples

State Bank.

14. Develope [sic] and Coordinate a Speech Contest for Students at the School.

Give Savings Bonds as prizes.

15. Send Thank You Cards to new Customers.

16. Coordinate Senior Citizens Programs.

17. Sponsor Summer Reading Program at Library — Savings Bonds to top

Readers.

Id.

7

See defendant’s evidentiary submission, appended to doc. no. 8, Tab 1 (Affidavit of Laura

Sullivan), at Exhibit A (People’s State Bancshares, Inc. Long-Term Disability Plan). The term

“employee welfare benefit plan” is defined by ERISA as 

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B. The People’s Plan

As a full-time employee, plaintiff obtained long-term disability insurance

coverage under an employee welfare benefit plan (“the People’s Plan” or “the Plan”)

issued by Met Life and governed by ERISA.7

 Met Life served as the claims

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 4 of 26
any plan, fund, or program which was heretofore or is hereafter established or

maintained by an employer or by an employee organization, or by both, to the extent

that such a plan, fund, or program was established or is maintained for the purpose

of providing for its participants or their beneficiaries, through the purchase of

insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits

in the event of . . . disability.

29 U.S.C. § 1002(1). Plaintiff acknowledges the Plan is covered by ERISA. See Complaint, at ¶ 4

(“[T]he above-described policy of insurance or plan is subject to the provisions of 29 U.S.C. § 101,

et seq., more commonly known as Employment [sic] Retirement Income Security Act.”).

8

 Sullivan Affidavit, at Exhibit A (People’s State Bancshares, Inc. Long-Term Disability

Plan), at document bearing Bates Stamp No. Met Life 00364 (“In carrying out their respective

responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have

discretionary authority to interpret the terms of the Plan and to determine eligibility for and

entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or

determination made pursuant to such discretionary authority shall be given full force and effect,

unless it can be shown that the interpretation or determination was arbitrary and capricious.”).

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administrator for the Plan, and was afforded both the discretionary authority to

interpret terms of the Plan with regard to benefit claims such as plaintiff’s, and the

authority to decide claim appeals.8

 The pertinent provisions of the Plan define a

disability as follows: 

“Disability” or “Disabled” means that, due to an Injury or Sickness,

you require the regular care and attendance of a Doctor and:

1. You are unable to perform each of the material duties of

your regular job; and

2. After the first 24 months of benefit payments, you must

also be unable to perform each of the material duties of any

gainful work or service for which you are reasonably

qualified taking into considerationyourtraining,education,

experience and past earnings; or

3. You, while unable to perform all of the material duties of

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 5 of 26
9

Id. at document bearing Bates Stamp No. Met Life 00355 (boldface emphasis in original).

10 Id. at documents bearing Bates Stamp Nos. Met Life 00356-00357 (boldface emphasis in

original, italicized emphasis supplied). The term “Elimination Period” is defined in the Plan as “The

later of 180 days or the end of a Period of Disability for which you are receiving Short Term

Disability Benefits under This Plan.” Id. at document bearing Bates Stamp No. Met Life 00350.

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your regular job on a full-time basis, are:

a. performing at least one of the material duties of your

regular job or any other gainful work or service on

a part-time or full-time basis; and

b. earning currently at least 20% less per month than

your indexed Basic Monthly Earnings due to that

same Injury or Sickness.9

The Plan requires long-term disability claimants to provide proof of a disability

meeting the foregoing definition in order to receive benefits, as follows:

1. Disability Benefit.

When we receive proof that you are Disabled, we will pay a

Monthly Benefit in accordance with the SCHEDULE OF BENEFITS.

However, the amount of the Monthly Benefit when added to any

compensation you may earn while Disabled, cannot exceed your

Indexed Basic Monthly Earnings. When this happens, your Monthly

Benefit will be reduced by the amount in excess of your Indexed Basic

Monthly Earnings.

The Monthly Benefit will be paid to you after completion of the

EliminationPeriod,shown in the SCHEDULE OF BENEFITS, provided

you remain Disabled and proof of continued Disability is submitted, at

your expense, to us upon request.10

Proof of a claim must be presented “not later than 90 days . . . following the end of

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 6 of 26
11 Id. at document bearing Bates Stamp No. Met Life 00360.

12 Id.

13 Id. at document bearing Bates Stamp No. Met Life 00363 (emphasis supplied).

14

 Defendant’s evidentiary submission, appended to doc. no. 8, Tab 1 (Affidavit of Laura

Sullivan), Exhibit B (Claim File), at documents bearing Bates Stamp Nos. Met Life 00345-00346.

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the Elimination Period in the case of Long Term Disability Benefits.”11 “If notice or

proof is not given on time, the delay will not cause a claim to be denied or reduced

as long as the notice or proof is given as soon as possible.”12

 

The Plan also provides the following with regard to a claimant’s right to

request a review of a denial of benefits:

In the event a claim has been denied in whole or in part, you or,

if applicable, your Eligible Survivor can request a review of your claim

by Metropolitan. This request for review should be sent to Group

Insurance Claims Review at the address of Metropolitan’s office which

processed the claim within 60 days after you or, if applicable, your

Eligible Survivor received notice of denial of the claim. When

requesting a review, please state the reason you or, if applicable, your

Eligible Survivor believe the claim was improperly denied and submit

any data, questions or comments you or, if applicable, your Eligible

Survivor deems appropriate.13

C. Plaintiff’s Claim for Long-Term Disability Benefits

Plaintiff initially filed for long-term disability benefits in October of 1996, due

to vocal cord dysfunction and asthma.14 On the Attending Physician Statement

submitted with her application, Dr. Carol Motley indicated plaintiff was currently

undergoing treatment and stated, “hopefully [her] condition will be successfully

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 7 of 26
15 Id. at document bearing Bates Stamp No. Met Life 00345.

16 Id. at document bearing Bates Stamp No. Met Life 00001.

17 Id. at documents bearing Bates Stamp Nos. Met Life 00288-290.

18 Id.

19 Id. at document bearing Bates Stamp No. Met Life 00007.

20 Id. at document bearing Bates Stamp No. Met Life 00083. Dr. Davis described the history

of plaintiff’s vocal disorder as follows:

Ms. Atchley [plaintiff’s former name] is a 30-year-old woman with a long history of

asthma complicated by paradoxical vocal cord movements. Ms. Atchley states that

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treated and she will be able to resume work.”15 On March 28, 1997, Met Life noted

in plaintiff’s file that her doctors expected her condition to last at least five years.16

After reviewing plaintiff’s application and the medical information submitted, Met

Life approved plaintiff’s claim, and it informed her on May 14, 1997 that she would

receive benefits effective retroactively to February 17, 1997.17 In Met Life’s letter to

plaintiff, it reminded her that it would “periodically require updated medical

certification for [her] claim.”18 

Met Life continued to receive medical updates from plaintiff through

approximately the end of 1997. On September 9, 1997, Met Life noted that plaintiff

had stopped the experimental Bio Tox Therapy she had been receiving for her vocal

cord dysfunction, because the treatments were ineffective.19 Met Life also received

a letter dated June 16, 1997, from Dr. Thomas L. Davis, Associate Professor of

Neurology at Vanderbilt University Medical Center. Dr. Davis stated that, at that

time, plaintiff was “100% disabled because of her voice.”20 Met Life noted in

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 8 of 26
she was hospitalized late last year for a typical asthma exacerbation and during that

hospitalization developed stridor and severe shortness of breath. It was at that time

that she acutely lost her voice. She then underwent multiple systematic treatments

including high dose benzodiazepine and antibiotics. Following one course of

antibiotics her voice improved significantly but her symptoms then exacerbated after

she returned to work for one week. She now states that breathing most of the time

is difficult for her and that she rarely speaks above a whisper. There are, however,

brief times when her voice is near normal. After speaking most of the day, she states

that her voice becomes unintelligible. Her throat feels full but does not hurt. She

complains of difficulty swallowing solids but not liquids. She denies any tongue

biting, jaw clinching, or involuntary tongue protrusions. 

Id. The court notes, however, that Dr. Davis was not treating plaintiff for her voice disorder; instead,

he appears to have been evaluating her to determine the cause of a tremor. See id. 

21 Id. at document bearing Bates Stamp No. Met Life 00007.

22 Id. at documents bearing Bates Stamp Nos. Met Life 00009-00010.

23 Id. at document bearing Bates Stamp No. Met Life 00012.

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plaintiff’s file on September 9, 1997, that Dr. Mark Courey at the Vanderbilt Voice

Center recently had informed plaintiffthat her condition was not expected to improve,

and that she was “totally & perm[anently] disabled.”21 On November 11, 1997, Met

Life noted that plaintiff had exhausted all non-surgical treatment options, and on

November 17, 1997, plaintiff’s speech therapist indicated she had reached her

maximum level of medical improvement.22 Plaintiff informed Met Life in December

of 1997 that she did not intend to return to work after she began receiving Social

Security disability benefits, because she preferred to stay home and care for her

children.23

Met Life paid plaintiff’s benefits until October of 1998, at which time it

suspended payments due to plaintiff’s failure to provide updated medical information

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 9 of 26
24 Id. at document bearing Bates Stamp No. Met Life 00229.

25 Id. at document bearing Bates Stamp No. Met Life 00016.

26 Id. at documents bearing Bates Stamp Nos. Met Life 00060-00062.

27 Id. at documents bearing Bates Stamp Nos.MetLife00156-00158. One medical dictionary

defines a “tracheostomy” as 

the surgical creation of an opening into the trachea through the neck, with the

tracheal mucosa being brought into continuity with the skin; also, the opening so

created. The term is also used to refer to creation of an opening in the anterior

trachea for insertion of a tube to relieve upper airway obstruction and to facilitate

ventilation. 

Dorland’s Illustrated Medical Dictionary 1727 (28th ed. 1994).

28 Id. at document bearing Bates Stamp No. Met Life 00021.

29 Id. at documents bearing Bates Stamp Nos. Met Life 00018-00021.

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upon Met Life’s request.24 Met Life claims it sent plaintiff two written requests for

updated medical records, but plaintiff claims she did not receive either request. In

May of 1999, after learning her benefits had been suspended, plaintiff requested

forms for her medical providers to complete.25 Plaintiff subsequently forwarded the

completed forms, along with updated medical records, to Met Life, and Met Life

notified her on October 13, 1999, that it would reinstate her claim and approve the

payment of continued benefits, retroactive to October of 1998.26

In the meantime, during March of 1999, plaintiff underwent surgery to have a

permanent tracheostomy placed in her throat for opening up her airway.27 A valve

was installed in the tracheostomy to allow plaintiff to speak,28 but plaintiff still

sometimes experienced significant difficulty communicating.29 Met Life noted in

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 10 of 26
30 Id. at document bearing Bates Stamp No. Met Life 00018.

31 Id. at documents bearing Bates Stamp Nos. Met Life 00019-00020.

32 Id. at document bearing Bates Stamp No. Met Life 00020.

33 Id. at document bearing Bates Stamp No. Met Life 00053.

34 Id. at document bearing Bates Stamp No. Met Life 00022.

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plaintiff’s file on September 10, 1999, that, due to the tracheostomy, it was possible

that continued coverage beyond May of 1999 would be warranted.30 However, Met

Life subsequently noted that, despite the tracheostomy, plaintiff might be able to

return to some type of work after a period of recovery, and that additional medical

records would be necessary to evaluate that possibility.31 Plaintiff subsequently

underwent a second surgery on September 15, 1999, because her tracheostomy had

begun to shut down.32 

Met Life received a completed questionnaire from Dr. Courey on February 10,

2000. Dr. Courey indicated that plaintiff had reached a maximum level of

improvement, and stated that plaintiff’s voice was permanently hoarse. He also stated

that plaintiff should avoid dry, smokey, or chemical-filled air, and that she would

require the intermittent use of humidifiers.33 Approximately one week later, Met Life

noted in plaintiff’s file that “her doctors are supporting a permanent and total

disability.”34

Met Life arranged for plaintiff to undergo a home evaluation by registered

nurse Opal Newcomb on November 7, 2000. Following her evaluation, Ms.

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 11 of 26
35 Id. at document bearing Bates Stamp No. Met Life 00049.

36 Id. at documents bearing Bates Stamp Nos. Met Life 00025-00026.

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Newcomb stated the following with regard to plaintiff’s potential for returning to

work:

The claimant has indicated she does not plan to return to work due

to her disabilities and due to the negative impact of any potential

employment. The claimant has indicated she requires daily rest in

between activities. The claimant has indicated any type of stress and

anxiety increases her symptoms, requiring more oxygen. The claimant

also requires daily suctioning throughout the day as well as dressing

changes around the trach site. Due to these reasons an eight hour work

day would most likely be very difficult for the claimant and any

potential employer and would most likely have a negative impact. The

claimant does enjoy using her home computer. The claimant has voiced

that she is only capable of performing any tasks for about 30 minutes,

including the use of her computer. Working from the home could

possibly be an option, however the claimant has indicated she does not

plan to return to any type of work environment. There is also the

possibility working from the home could cause a stressful situation,

increasing symptoms. Limitations in regard to return to work are noted

to be the trach and appearance, need for frequent suctioning, daily

oxygen needs as needed, dressing changes daily included throughout the

day, easily fatigued and need for frequent rest periods.35

Based on this information, and particularly on plaintiff’s statement that she was not

interested in returning to work, Met Life indicated in plaintiff’s file on November 22,

2000, that it did not consider her a good candidate for vocational rehabilitation, and

it closed her file with regard to rehab at that time.36 

In 2001, Met Life again requested continued proof of plaintiff’s disability. Met

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 12 of 26
37 Id. at documents bearing Bates Stamp Nos. Met Life 00026, 00034, & 00035. 

38 Id. at document bearing Bates Stamp No. Met Life 00034.

39 Id. at document bearing Bates Stamp No. Met Life 00035.

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Life claims it sent plaintiff two letters in June and July of 2001, requesting additional

medical records to support plaintiff’s entitlement to benefits.37 However, Met Life

did not produce a copy of these letters, and plaintiff disputes that she ever received

them. Met Life subsequently sent plaintiff a letter on August 20, 2001, stating:

We wrote to you on June 15, 2001 and July 19, 2001 requesting

that you send us a current medical statement from your attending

physician. To date, we have not received a reply.

As we still have not received the required medical statement

showing your present condition, we can only assume that you are not

claiming further benefits. Therefore, no further benefits will be payable

starting September 30, 2001.

If the required medical statement is not received within 30 days,

we will have to terminate your claim effective October 1, 2001.38

Met Life still did not receive the requested medical information, and it

consequently sent plaintiff a letter on November 8, 2001, notifying her that her claim

had been terminated, and reminding her that she had the right to request a review

within sixty days after she received notice of the denial.39 Despite this clear directive,

plaintiff did not contact Met Life until December of 2003, when she wrote a letter

requesting an appeal of the denial of her claim. She stated:

This is the third time I have sent a letter of appeal to ya’ll [sic]

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 13 of 26
40 Id. at documents bearing Bates Stamp Nos. Met Life 00031-00032.

41 Id. at document bearing Bates Stamp No. Met Life 00033.

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and they say you have not received them. I am writing this letter to get

my disability picked back up from Sept. 2001 when you all stopped

paying me. I was unaware for over a year that you were not paying me.

My exhusband was taking care of all our business and he told me

nothing when I became aware of what he was doing it has taken awhile

[sic] to get things together and try to fix what he’s done. I sent the first

appeal letter to yall [sic] over a month ago, then I sent another about two

weeks ago so I would appreciate some kind of response to let me know

that you received this letter. I am still disabled. I have not worked since

‘96 . . . .40

Met Life’s records do not reflect that plaintiff’s ex-husband ever inquired about

plaintiff’s claim, or that he was handling her affairs. 

Met Life mailed plaintiff a letter on January 20, 2004, informing her: “We are

unable to give your request further consideration since it was received December 23,

2003, which is two years beyond the expiration of the 60 day appeals submission time

period. No further review or appeal of the denial will be considered.”41 The file does

not reflect that plaintiff ever provided any additional medical records responsive to

Met Life’s requests. Plaintiff filed this suit on April 5, 2004.

II. DISCUSSION

As a threshold matter, the court must determine the appropriate standard for

reviewing Met Life’s denial of plaintiff’s claim for benefits, because ERISA does not

specify the standard applicable to the decisions of a plan administrator or fiduciary.

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 14 of 26
42 These standards apply not only to an administrator’s interpretation of a plan term, but also

to factual decisions of an administrator, such as the decision in this case to deny plaintiff’s benefits.

See Shaw v. Connecticut General Life Insurance Co., 353 F.3d 1276, 1284-85 (11th Cir. 2003).

43 Plaintiff seems to consent that the “arbitrary and capricious” standard applies. See doc. no.

15 (plaintiff’s brief), at unnumbered page 6.

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See Jordan v. Metropolitan Life Insurance Co., 205 F. Supp. 2d 1302, 1305 (M.D.

Fla. 2002) (citing, e.g., Marecek v. BellSouth Telecommunications, 49 F.3d 702, 705

(11th Cir. 1995) (other citation omitted)). 

The Supreme Court held in Firestone Tire & Rubber Co. v. Bruch, 489 U.S.

101 (1989), that “a denial of benefits . . . is to be reviewed under a de novo standard

unless the benefit plan gives the administrator or fiduciary discretionary authority to

determine eligibility for benefits or to construe the terms of the plan.” Id. at 115.

Pivoting off the Bruch decision, the Eleventh Circuit has promulgated three standards

of review applicable to the decisions of a claim administrator: “(1) de novo where the

plan does not grant the administrator discretion; (2) arbitrary and capricious [where]

the plan grants the administrator discretion; and (3) heightened arbitrary and

capricious where there is a conflict of interests.” Buckley v. Metropolitan Life

Insurance Co., 115 F.3d 936, 939 (11th Cir. 1997).42 Here, the plan grants the claims

administrator the discretion to construe the terms of the Plan, and to determine a

claimant’s eligibility for benefits. Accordingly, the “arbitrary and capricious”

standard applies.43

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 15 of 26
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To determine whether the administrator’s decision was arbitraryand capricous,

the court must first “[a]pply the de novo standard to determine whether the claim

administrator’s benefits-denial decision is ‘wrong’ (i.e., the court disagrees with the

administrator’s decision).” Williams v. Bellsouth Telecommunications, Inc., 373 F.3d

1132, 1138 (11th Cir. 2004) (citing HCA Health Services of Georgia, Inc. v.

Employers Health Insurance Co., 240 F.3d 982, 993 n.23 (11th Cir. 2001)). If the

decision was not “wrong,” the inquiry is ended and the administrator’s decision will

be affirmed. Williams, 373 F.3d at 1138. 

If the administrator’s decision is “wrong,” then, under the arbitrary and

capricious standard of review, the court next must “determine whether ‘reasonable

grounds’ supported it.” Id. (citation omitted). Stated differently, 

[w]hen conducting a review of an ERISA benefits denial under an

arbitrary and capricious standard (sometimes used interchangeably with

an abuse of discretion standard), the function of the court is to determine

whether there was a reasonable basis for the decision, based upon the

facts as known to the administrator at the time the decision was made.

Jett v. Blue Cross and Blue Shield of Alabama, Inc., 890 F.2d 1137, 1139 (11th Cir.

1989) (citations omitted). A reasonable decision will be upheld as not being arbitrary

and capricious “even if there is evidence that would support a contrary decision.” Id.

at 1140.

Met Life offers two, primary arguments to support the proposition that its

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 16 of 26
44 See defendant’s evidentiary submission, appended to doc. no. 8, Tab 1 (Affidavit of Laura

Sullivan), Exhibit B (Claim File), at documents bearing Bates Stamp Nos. Met Life 00356-00357

(“The Monthly Benefit will be paid to you after completion of the Elimination Period, shown in the

SCHEDULE OF BENEFITS, provided you remain Disabled and proof of continued Disability is

submitted, at your expense, to us upon request.”) (emphasis supplied).

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decision to deny plaintiff’s benefits was not arbitrary and capricious. First, Met Life

asserts that plaintiff failed to submit proof of continued disability as required by the

Plan. Second, Met Life asserts that plaintiff failed to exhaust her administrative

remedies before filing suit.

A. Failure to Provide Proof of Continued Disability

Met Life asserts that plaintiff is not entitled to benefits under the Plan because

she failed to provide requested medical information to establish her continued

disability. 

A plan participant’s entitlement to benefits “can only be found if it is

established by contract under the terms of the ERISA-governed benefit plan

document.” Alday v. Container Corp. of America, 906 F.2d 660, 665 (11th Cir. 1990)

(citing Moore v. Metropolitan Life Insurance Co., 856 F.2d 488, 492 (2d Cir. 1988)).

Here, the Plan documents require a claimant to submit proof of disability before

benefits will be paid, and to submit proof of continued disability upon request in

order to maintain benefits.44 The last medical records in plaintiff’s claim file are

dated November of 2000. Met Life requested that plaintiff update her records to

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 17 of 26
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provide proof of continuing disability on June 15 and July 19, 2001. Plaintiff did not

respond to Met Life’s requests. On August 20, 2001, Met Life cautioned plaintiff that

if she did not produce supplemental medical records, her benefits would be

terminated. Plaintiff still did not provide the requested records, and Met Life

consequently terminated her benefit payments on November 8, 2001. 

These circumstances are analogous to those presented in Buckley, supra,

another case involving a long-term disability plan issued by Met Life. In Buckley, the

plan

provided that a recipient of disability income might “be required not

more often than semi-annually to undergo a medical examination by a

physician or physicians appointed by the Committee and/or submit

evidence of continued Total Disability satisfactory to the Committee.”

The Plan further stipulated that “if the Member refuses to submit to a

medical examination or to submit evidence of Total Disability as

required by the Committee, his disability income under the Plan shall

cease as of the date of such determination or refusal.”

Buckley, 115 F.3d at 937-38. Met Life requested Buckley to produce a medical form

on several occasions, but Buckley did not comply. Id. at 938. Met Life subsequently

informed Buckley that her benefits would be terminated effective September 1, 1992,

if she did not produce the form. Id. Buckley did not comply in a timely manner, and

Met Life consequently decided to terminate her benefit payments. Id. Buckley

eventually did produce the requested form, but Met Life stood by its denial decision.

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 18 of 26
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The district court, employing the “arbitrary and capricious standard,” upheld Met

Life’s denial of benefits. The Eleventh Circuit affirmed on appeal, because Buckley

“had failed to submit the required proof of her continuing disability.” Id. at 941.

Similarly, here, Met Life provided plaintiff ample opportunity to submit proof

of her continued disability, and she repeatedly failed to do so. Accordingly, Met Life

had the right under the plain language of the Plan to terminate plaintiff’s benefits, and

it was not “wrong” or “unreasonable” for it to do so. See id. (Met Life’s decision to

deny benefits based on the claimant’s failure to provide proof of disability was

“reasonable”);see also Grayer v. Liberty Life Assurance Co. of Boston, 331 F. Supp.

2d 1383, 1390-91 (M.D. Fla. 2004) (the plan administrator’s decision to deny longterm disability benefits due to the claimant’s failure to provide requested medical

information was “correct and reasonable”).

Plaintiff’s arguments to the contrary are unavailing. First, plaintiff asserts that

Met Life may not have actually sent her letters in June and July of 2001, because

copies of those letters are not in the administrative record. This fact is immaterial,

however, because plaintiff does not dispute that Met Life sent letters in both August

and November of 2001, or that she failed to submit any medical records after

becoming aware of the denial of her claim. 

Plaintiff also asserts that she was unaware both of Met Life’s requests for

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 19 of 26
45 Id. at documents bearing Bates Stamp Nos. Met Life 00031-00032.

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information, and of the denial of her claim, because her ex-husband had been

handling her personal affairs, and he did not inform her of the requests or the denial.

However, plaintiff stated in December of 2003 that she had been “unaware for over

a year” that her benefits had ceased.45 By that time, plaintiff had not received benefits

for more than two years. She offers no explanation for why she was unaware she was

not receiving benefits for the remainder of that two-year time period. In addition,

plaintiff offers no indication that she was incapable of handling her own affairs

during this two-year time period. Indeed, plaintiff’s subsequent, untimely request for

review of her claim, and her pursuit of this lawsuit, indicate that she is capable of

managing her affairs. Accordingly, she should have been aware of Met Life’s

correspondence, and the Plan language requiring her to submit continued proof of

disability upon request. See Barnes v. Lacy, 927 F.2d 539, 543 (11th Cir. 1991)

(holding that participants in an ERISA plan had constructive knowledge of the plan’s

terms).

Additionally, plaintiff asserts that Met Life should never have ceased paying

her benefits because it already had sufficient information in the record to support her

disability. It is true that plaintiff’s medical records reflected she had a permanent

tracheostomy, and that she suffered from impairments in her speech and activities due

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 20 of 26
46 Further, the medical records which were in plaintiff’s claim file reflected some

inconsistencies. In addition to the statements that plaintiff was permanently disabled, therewere also

indications that she had some chance for improvement, or that she retained some capacity to work.

The initial Attending Physician Statement plaintiff submitted stated that “hopefully [plaintiff’s]

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to her condition. Indeed, portions of plaintiff’s medical records indicated that she

was “permanently and totally disabled,” that her condition was not likely to improve,

and that she had exhausted certain treatment options. These statements are not

dispositive, however, because the Plan requires proof of continued disability upon

request. In Buckley, the Eleventh Circuit upheld the plan administrator’s denial of

disability benefits based on Buckley’s failure to provide proof of continued disability,

despite a physician’s prior indication that Buckley was “permanently and totally

disabled.” Buckley, 115 F.3d at 938. The Court stated:

It is important to understand that Buckley’s benefits were not terminated

because the Committee found that she was no longer disabled, but

because she had failed to submit the required proof of her continuing

disability. At the time the Committee voted to terminate Buckley’s

benefits on December 8, 1992, it had not received the required form

attesting to Buckley’s continuing disability or any other written

communication regarding the matter from Buckley since the previous

May. Based on those facts, the Committee’s decision was clearly not

arbitrary and capricious. 

Id. at 941.

Similarly, here, Met Life did not deny plaintiff’s continued benefits because

she was no longer disabled. Rather, it denied her benefits because she did not

produce the required proof of her continued disability.46

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 21 of 26
condition will be successfully treated and she will be able to resume work.” Id. at document bearing

Bates Stamp No. Met Life 00345. Following plaintiff’s tracheostomy, Met Life noted that plaintiff

might be able to return to some type of work after a period of recovery. Id. at documents bearing

Bates Stamp Nos. Met Life 00019-00020. The home study evaluation summary completed by

Registered Nurse Opal Newsome in November of 2000 indicated that plaintiff might be able to work

from home. Given these inconsistencies in the reports about plaintiff’s condition, it was not

“unreasonable” for Met Life to request additional medical records to support plaintiff’s continued

entitlement to disability 

47 Plaintiff’s brief, at unnumbered page 8.

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Finally, plaintiff asserts that Met Life “arbitrarily and capriciously decided not

to obtain further medical evidence of their own investigation, as they had previously

done on numerous occasions in the past concerning this claim.”47 However, plaintiff

cites no authority to support the proposition that Met Life had a duty to independently

request information to support her entitlement to benefits. To the contrary, a plaintiff

suing for a denial of benefits under ERISA “bears the burden of proving [her]

entitlement to contractual benefits.” Horton v. Reliance Standard, 141 F.3d 1038,

1040 (11th Cir. 1998) (citing Farley v. Benefit Trust Life Insurance Co., 979 F.2d

653, 658 (8th Cir. 1992)). “This burden is the same whether or not the administrator

denies a claim initially or decides to discontinue benefits after initially approving

them.” Richards v. Hartford Life and Accident Insurance Co., 356 F. Supp. 2d 1278,

1284 (S.D. Fla. 2004) (citing Hufford v. Harris Corp., 322 F. Supp. 2d 1345, 1360

(M.D. Fla. 2004)). 

In other words, there is no shifting of the claimant’s burden of proof to

establish a disability once a plan administrator honors a claim. As a

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 22 of 26
48 Plaintiff also suggests that Met Life’s denial of benefits was arbitrary and capricious

because it occurred after plaintiff stated she did not intend to return to the workforce. See plaintiff’s

brief, at unnumbered page 9. Plaintiff seems to imply that Met Life has a pattern of requesting

additional medical information to support a continued disability, and denying plaintiff’s benefits for

failure to provide the requested information, only after plaintiff has stated her intention to not return

to the workforce. Plaintiff cites no authority to support her argument that these circumstances

constitute an abuse of Met Life’s discretion. In addition, the court finds no support for plaintiff’s

theory in the record. It is true that the first denial of plaintiff’s benefits in October of 1998 occurred

approximately ten months after plaintiff informed Met Life of her intent not to rejoin the workforce.

The second denial of plaintiff’s benefits occurred approximately one year after plaintiff formed Opal

Newcomb, the Registered Nurse hired by Met Life, that she did not intend to return to the work

force. These time gaps of ten months and one year, respectively, are not sufficiently close to suggest

a causal connection between plaintiff’s statements of intent, and Met Life’s subsequent denials of

benefits. Further, a more careful examination of the record reflects that, both times Met Life denied

plaintiff’s claim for benefits, it did so after a long period of receiving no medical records from

plaintiff, despite repeated requests from Met Life. Plaintiff’s suggestion of some improper motive

on the part of Met Life simply is insufficient to overcome the fact that plaintiff was required to

submit proof of continued disability upon request, and she failed to do so.

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result of the payment of benefits, the plan does not incur the burden of

showing a change in claimant’s condition in order to justify a

termination of benefits; the claimant retains the burden of proving

continued disability.

Hufford, 322 F. Supp. 2d at 1360 (citation omitted). The language of the Plan

comports with this legal principle, as it requires a claimant to provide medical

documentation, upon Met Life’s request, to support a continued disability.48

In summary, it was not “wrong” for Met Life to deny plaintiff’s claim for

disability benefits, because plaintiff failed to provide proof of continued disability,

as required by the Plan. Even if Met Life’s denial of benefits could be considered

“wrong,” however, Met Life’s decision was not “arbitrary and capricious,” because

it had a reasonable basis for the denial.

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 23 of 26
49 Plaintiff offers little response to defendant’s exhaustion argument, except to state,

“[c]learly, Ms. Willmon’s claim for URISA [sic] benefits was timely in the court system.” Plaintiff’s

brief, at unnumbered page 9. 

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B. Failure to Exhaust Administrative Remedies

Met Life also argues that plaintiff failed to exhaust her administrative remedies

prior to filing suit.49 It is well-settled that “‘plaintiffs in ERISA actions must exhaust

available administrative remedies before suing in federal court.’” Perrino v. Southern

Bell Telephone & Telegraph Co., 209 F.3d 1309, 1315 (11th Cir. 2000) (quoting

Counts v. American General Life and Accident Insurance Co., 111 F.3d 105, 108

(11th Cir. 1997), and also citing Springer v. Wal-Mart Associates’ Group Health

Plan, 908 F.2d 897, 899 (11th Cir. 1990), and Mason v. Continental Group, Inc., 763

F.2d 1219, 1225-27 (11th Cir. 1985)). This exhaustion requirement is “strictly

enforce[d]” by the Eleventh Circuit, and it applies when an ERISA plaintiff fails to

request a timely review of the denial of her claim. Perrino, 209 F.3d at 1315.

For example, in Stephenson v. Provident Life & Accident Insurance Co., 1 F.

Supp. 2d 1326 (M.D. Ala. 1998), the insurer terminated Stephenson’s disability

benefits and informed her that she had 60 days to request an appeal, in accordance

with the applicable plan documents. Id. at 1330-31. Stephenson requested a review

of the denial approximately two and one-half months after the sixty-day period had

expired. Id. The insurer consequently denied her appeal as untimely, and when

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 24 of 26
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Stephenson later filed suit, the district court entered summary judgment on behalf of

the insurer due to Stephenson’s failure to exhaust administrative remedies. Id. at

1331-32.

Similarly, here, the People’s Plan requires a participant whose benefits are

denied to file a request for review within sixty (60) days of receiving notice of the

denial. In the denial letter Met Life sent to plaintiff on November 8, 2001, it

reminded her of this sixty-day appeal period. Nonetheless, plaintiff did not contact

Met Life to request a review of her claim until December of 2003, more than two

years later. Plaintiff’s request clearly was untimely, and Met Life was entitled to

decline plaintiff’s appeal. Accordingly, plaintiff failed to exhaust her administrative

remedies under the Plan, and summary judgment is due to be granted on those

grounds. See, e.g., Perrino, 209 F.3d at 1319 (affirming the entry of summary

judgment due to failure to exhaust administrative remedies); Counts, 111 F.3d at 109

(same); Merritt v. Confederation Life Insurance Co., 881 F.2d 1034, 1035 (11th Cir.

1989) (same).

III. CONCLUSION

In accordance with the foregoing, summary judgment is due to be granted on

plaintiff’s ERISA claim because she failed to provide proof of continued disability,

as required by the Plan, and because she failed to exhaust her administrative remedies

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 25 of 26
50 Plaintiff’s state law claims for bad faith and breach of contract also are due to be dismissed,

because they are preempted by ERISA. See Gilbert v. Alta Health & Life Insurance Co., 276 F.3d

1292, 1296-1301 (11th Cir. 2001) (ERISA preempts bad faith claims); Swerhun v. Guardian Life

Insuarnce Co., 979 F.2d 195, 198 (11th Cir. 1992) (ERISA preempts breach of contract claims).

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before filing suit.50 An appropriate order will be entered contemporaneously

herewith. 

DONE this 28th day of November, 2005.

______________________________

United States District Judge

Case 5:04-cv-01108-CLS Document 17 Filed 11/28/05 Page 26 of 26