Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_01-cv-02075/USCOURTS-azd-2_01-cv-02075-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Mark J. Schwartz,

Plaintiff, 

vs.

Metropolitan Life Insurance Company, a

New York corporation; American Express

Long Term Disability (LTD) Benefit Plan,

Defendants. 

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No. CIV-01-2075-PHX-MHM

ORDER

Plaintiff has asserted a claim for disability benefits under an employee welfare benefit

plan governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §

1001, et seq. Defendants are Metropolitan Life Insurance Company ("MetLife") and

American Express Long Term Disability Benefit Plan. This case is before the Court

following remand from the Court of Appeals for the Ninth Circuit. The Ninth Circuit

reversed and remanded with instructions to apply a de novo standard of review. (Doc. 53).

Plaintiff has filed a motion for summary judgment (Doc. 61) supported by a separate

statement of facts. (Doc. 26). Defendants have filed a cross-motion for summary judgment

(Doc. 60) supported by a separate statement of facts (Doc. 20). The parties have filed

appropriate responses and replies. (Doc. 37, 62-64, 67).

Case 2:01-cv-02075-MHM Document 68 Filed 03/31/06 Page 1 of 21
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I.

Background Facts.

A. Relevant Plan Provisions.

Plaintiff was a participant in the American Express Employee Benefits Plan (the

"Plan") which provided long-term disability ("LTD") coverage through a group disability

insurance policy purchased from MetLife. The Plan is governed by ERISA. Pursuant to the

terms of the Plan, a person who is enrolled in the LTD Benefit Plan and who has been totally

disabled and prevented from working for six consecutive months is eligible to apply for

monthly LTD benefits following that six-month period. 

The Plan provides “own occupation” coverage for the first 24 months that benefits are

payable and states in part as follows: 

You are considered totally disabled and eligible to apply for

LTD Benefit Plan benefits if, during the six-month waiting

period and the first two years that benefits are payable, you are

unable to perform any and every duty of your own occupation

due to a medically determined physical or mental impairment

caused by sickness, disease, injury or pregnancy. You must

require the regular care and attendance of a doctor.

After the first two years, coverage is provided under the “any occupation” standard and the

Plan provision relevant to this coverage provides as follows:

To receive benefits after the first two years that benefits are

payable, you must be under the care and attendance of a licensed

physician and your disability must prevent you from engaging

in each of the material duties of any gainful work or service for

which you are reasonably qualified, taking into consideration

your training, education, experience and past earnings (except

rehabilitative employment).

The Plan provides that if a person becomes totally disabled before age 60, benefits

will continue as long as the person is totally disabled, up to age 65 "(unless [the person] [is]

disabled due to mental illness, as defined ...") in another section of the Plan. The Plan

provides limited coverage for disability due to mental illness as follows: 

If you are disabled due to mental illness, benefits are limited to

24 months if treatment is rendered on an outpatient basis ... If

you do not return to work at the end of the 24-month period ...

your LTD coverage will end. Mental illness is defined as a

mental, emotional or nervous condition of any kind.

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The Plan's provisions set forth the procedures for filing claims and review of claims

for benefits, including an appeal if a claim is denied. In addition, "[T]he plan administrator

has the exclusive right to interpret the provisions of the plan and its decision is final,

conclusive and binding (except as otherwise provided in the plan or by law)." With respect

to proof of any claim, the Plan provides:

The claims administrator reserves the right to require

verification of any alleged fact or assertion pertaining to any

claim for benefits. For example, as part of the basis for

determining health care benefits, the claims administrator may

require submission of medical summaries, discharge reports, Xrays or other appropriate materials.

Plaintiff has provided evidence, based on deposition testimony of Defendants' official

Laura Sullivan, that if a disability involves a combination of physical and mental conditions,

MetLife's initial assessment focuses on whether the person is disabled overall. If the Plan

contains a 24-month limitation for mental/nervous conditions, such as the Plan at issue in this

case, MetLife continues to investigate to determine whether both conditions are disabling or

the nature of the actual cause of the condition. Ms. Sullivan further testified that if the

claimant is disabled by both mental and physical conditions, though neither alone is

disabling, benefits are payable beyond the 24-month period as stated in the Plan for "mental

illness." Plaintiff further has provided information through the testimony of MetLife's

employees and officials that MetLife's case managers and appeal specialists do not have any

medical training except in general medical terminology. 

B. Plaintiff's condition and application for benefits.

Plaintiff is an accountant with a history of hypertension (high blood pressure), high

cholesterol, and coronary artery disease (“CAD”). On January 30, 1999, at the age of 51,

Plaintiff underwent four-vessel coronary artery bypass surgery. On February 17, 1999, Dr.

Andrei Damian, Plaintiff’s cardiologist, noted that Plaintiff had done “well” regarding his

surgery and was discharged with an “excellent post surgical recovery.” Dr. Damian noted

that stress and anxiety experienced at work had contributed to Plaintiff’s cardiac condition

and he was initially scheduled to return to work on a part-time “trial” basis. Dr. Damian also

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referred Plaintiff to a hospital-based cardiac rehabilitation program. It was noted in this

rehabilitation plan that Plaintiff has a family history of early onset heart problems. The plan

focused on stress reduction as a rehabilitation goal. 

On March 11, 1999, Plaintiff’s internist, Dr. Jack Poles, noted that Plaintiff’s blood

pressure and general examination were “unremarkable.” A treadmill stress test on March 17,

1999, had “normal results”, with no subjective or objective evidence of coronary artery

disease, no arrhythmias and excellent exercise capacity.

However, shortly after surgery, Plaintiff began to experience exaggerated

psychological anxiety. On April 14, 1999, Plaintiff had his first appointment with Dr. David

Boyer, a psychiatrist, who diagnosed him as suffering “post bypass anxiety syndrome.” 

Plaintiff was released to return to work based on his physical recovery and returned to work

part-time on April 15, 1999. In a Rehabilitation Services Report dated April 15, 1999,

Plaintiff's physical therapist indicated that Plaintiff has said that stress was a contributing

factor. 

On June 14, 1999, a nurse's note indicated that Plaintiff had reported that his blood

pressure had become elevated and fluctuated and he experienced dizziness, palpitations, chest

pain and fatigue. 

On June 16, 1999, Dr. Poles reported that Plaintiff had been having a difficult time

with returning to work and that he lacked energy. Dr. Poles determined that Plaintiff needed

to be on total disability. Plaintiff ceased working permanently on June 16, 1999. On June

17, 1999, Dr. Poles wrote in a letter to Dr. Damian that Plaintiff’s EKG was “unremarkable”

and that he suspected Plaintiff’s condition was “more stress related.” Dr. Poles noted that

Plaintiff's blood pressure was high. Dr. Poles recommended "total disability", reporting to

Plaintiff's employer that Plaintiff was unable to perform his job and that this condition would

continue "indefinitely."

 On June 18, 1999, Dr. Damian's progress note indicated that Plaintiff was

“struggling” with anxiety and depression. Dr. Damian stated that he believed that "part of

his symptoms are related to intermittent hypertension up to 150/102." In June 1999,

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Plaintiff’s Holter Monitor results (a 24-hour test that monitored Plaintiff’s heart rate)

revealed underlying sinus rhythm with normal heart rate variability.

On June 25, 1999, Dr. Damian wrote to Dr. Poles that with medical management

Plaintiff's blood pressure had remained down. However, Dr. Damian noted "documented

clear evidence of hypertension and a blood pressure of 151/102." Dr. Damian expressed

concern about the development of Plaintiff's post bypass graft depression and anxiety, noting

that Plaintiff was currently undergoing psychotherapy. Dr. Damian did not believe Plaintiff

could return to work. A 24-hour Holter monitor had not revealed any evidence of malignant

dysrhythmia. On June 30, 1999, Dr. Damian reported to Plaintiff's employer that Plaintiff

suffered from depression, stress intolerance and labile hypertension related to anxiety, and

that he was unable to interact effectively with clients.

On July 15, 1999, Plaintiff's Nuclear Stress Test revealed an EKG portion with

excellent exercise capacity and heart rate attainment. There was no suggestion of ischemia

and the gated wall motion analysis revealed normal left ventricular function. On July 27,

1999, Dr. Damian reported that Plaintiff had excellent exercise capacity and documented an

excellent anatomical recovery but that stress and related symptoms including post bypass

anxiety prevented him from returning to routine employment. On September 16, 1999, Dr.

Poles reported that Plaintiff's symptoms seemed under control because he was not working

and that his physicians had concluded that he could not again work in his usual capacity

because of his reaction to job stress.

On October 13, 1999, Plaintiff complained to Dr. Damian of nonspecific chest

discomfort that did not appear cardiac in description. Dr. Damian reported an abnormal

finding that Plaintiff's blood pressure was 180/120; however, there was no evidence of

congestive heart failure or cardiac gallop. It was noted that Plaintiff was unable to deal

appropriately with stressful situations without putting himself at risk. On this same date, Dr.

Damian reported to the Social Security Administration that Plaintiff had "wonderful

improvement" following his heart treatment but he did not believe that Plaintiff could return

to a gainful employment, noting that Plaintiff is “affected negatively by any interaction with

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humanity, stress, or responsible work and accountability which will only compromise his life

span.” Dr. Damian wrote that Plaintiff had "developed significant anxiety post bypass

surgery which is consistent with post bypass stress and anxiety syndrome which appears

exacerbated continually with the severe presence of hypertension."

On October 14, 1999, MetLife wrote Plaintiff advising that he might be eligible for

LTD benefits and requested completion of a number of forms which were enclosed. On

October 25, 1999, Plaintiff completed a Statement of Claim requesting LTD benefits under

the Policy. 

On October 29, 1999, Dr. Poles reported that Plaintiff “clearly cannot perform at work

due to severe anxiety ...” On October 31, 1999, Dr. Poles completed an Attending Physician

Statement and Physical Capacities Evaluation for MetLife, stating that Plaintiff suffered from

coronary disease, anxiety, chest pain, sweats and palpitations. Dr. Polies indicated that

Plaintiff’s “problems are anxiety related not due to physical limitations. ...” 

Dr. Boyer's November 13, 1999 Attending Physician Statement stated that Plaintiff’s

psychological functions were at a Class 3-4 (marked limitation) due to “emotional factors

affecting a medical condition-anxiety and depression” and “obsessive compulsive personality

disorder.” Dr. Boyer stated that Plaintiff's acute anxiety and depression were expected to

abate, but not his underlying psychophysiologic vulnerability, e.g., significant blood

pressure increases under stress. Dr. Damian's November 17, 1999 Attending Physician

Statement stated that Plaintiff’s Psychological Functions were a Class 4 (marked limitations),

but that his Cardiac Functions were only a Class 2 (slight limitations). Dr. Damian stated

that Plaintiff suffered from severe post bypass anxiety syndrome and hypertension and he

was unable to engage in gainful activity. On November 22, 1999, MetLife wrote to Dr.

Damian requesting Plaintiff's medical records. 

On December 5-7, 1999, Plaintiff was self-admitted to the hospital for chest pain but

no cardiac problem was found. Hospital records noted a "status of post bypass graft surgery

with significant symptoms mostly related to post stress anxiety and evidence of hypertension

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which remain[ed] out of control until most recently when [Plaintiff] was placed on

continuous beta blockade." A treadmill Cardiolite documented excellent exercise capacity.

Dr. Damian's office visit note for December 27, 1999 stated that control of Plaintiff's blood

pressure had been achieved and Plaintiff did not appear to be under significant stress at that

time. 

In a January 12, 2000 letter, Dr. Damian responded to Provident Insurance Company

regarding an Independent Medical Exam performed by Dr. Michael Greer. Dr. Damian's

response stated that “[w]hile the objective stress treadmill data suggest an adequate surgical

result and presumes no limitations preventing a return to work ....In my opinion it is clear that

Mr. Schwartz’s disability at this point is caused by his post bypass anxiety syndrome and

secondary intermittent uncontrolled hypertension which is acutely exacerbated by his attempt

to return to work...” On January 22, 2001, Plaintiff received a Social Security total disability

award commencing July 1999 with primary diagnosis of “anxiety related disorder” and

secondary diagnosis of “personality disorder.”

MetLife had Plaintiff’s file reviewed by Dr. Jay Lasser, its consulting psychiatrist.

Dr. Lasser noted that Plaintiff wanted to return to work but his perfectionist tendencies and

entrenched personality issues were unlikely amenable to much change. Dr. Lasser

recommended that Plaintiff’s file be reviewed by a consultant with expertise in cardiology.

Plaintiff claims that MetLife did not have a cardiologist review his file. 

On February 17, 2000, a MetLife official reviewed Plaintiff's claim as a high liability

claim. The information on the review form indicated that Plaintiff's diagnosis was

"cardiovascular disease, anxiety, depression" and stated that "because of significant anxiety

disorder and personality components it is highly unlikely [Plaintiff] will improve enough to

return to any occupation."

On February 25, 2000, MetLife informed Plaintiff that his LTD claim had been

approved as a mental/nervous condition starting July 29, 1999 (the end of the six-month

elimination period) and that he was eligible to receive Plan benefits for 24 months, through

July 29, 2001, if he remained disabled. Plaintiff was re-notified of this information on April

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28, 2000 and May 15, 2000. On February 28, 2000, MetLife requested all of Plaintiff's

medical records from Dr. Damian. 

On March 22, 2000, Dr. Damian wrote Dr. Poles that Plaintiff had recently blacked

out and he possibly was experiencing orthostatic changes. Dr. Damian recommended concern

over possible transitory bradycardia or a heart block. Dr. Damian was not concerned with

hypertension at the present time. On March 29, 2000, Dr. Damian wrote Dr. Poles that a 24

hour Holter monitor documented a sinus rhythm with a first degree AV block and absence

of any significant periods of bradyarrhythmias. A change in medication had resulted in

Plaintiff's improved condition, noting that he was essentially asymptomatic. 

Dr. Poles' Attending Physician Statement dated May 28, 2000 stated that Plaintiff had

“anxiety related symptoms not physically impaired.” Plaintiff's diagnoses were listed as

including coronary disease, hypertension, anxiety at work, chest pain, sweats, and

palpitations. Dr. Poles noted that Plaintiff could not deal with stressful situations. Dr.

Damian's May 31, 2000 Attending Physician Statement discussed Plaintiff's coronary artery

disease, hypertension and inability to engage in stress situations or interpersonal

relationships. Dr. Boyer completed an Attending Physician Statement and supplemental

questionnaire on June 1, 2000 which indicated that Plaintiff "is unable to cope with the stress

of his career" and that he is unable to return to work. 

On June 10, 2000, Plaintiff completed an Activities of Daily Living form in which he

stated that stressful situations caused an increase in his blood pressure and that he had trouble

concentrating. Plaintiff stated he had had to scale back his volunteer work. 

In June 2000, Dr. Damian wrote that Plaintiff's blood pressure was well controlled

"in the absence of any active excitement." Dr. Boyer noted that Plaintiff had increased blood

pressure as a result of an incident when he misplaced his volunteer badge at the hospital. In

September 2000, Dr. Damian reported that even with minimal stress and anxiety, Plaintiff

was experiencing significant hypertension, and that a recent discussion concerning his

financial circumstances caused his blood pressure to become elevated. 

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On November 1, 2000, Dr. Poles reported that Plaintiff is “doing well from the

cardiovascular point of view except that he gets occasional stress-induced chest pain which

[Plaintiff] does not think is cardiac.” Dr. Poles stated that Plaintiff suffered from chest pain,

difficulty breathing, and hypertension when under stress due to such things as financial

concerns. 

On November 2, 2000, Plaintiff was admitted to the hospital for chest pain.

Examination revealed no active disease in the chest. A stress test revealed excellent

functional capacity, mild hypertensive response to exercise, and normal ST segment response

to exercise. A cardiac ultrasound revealed trivial mitral and tricuspid regurgitation and an

otherwise unremarkable 2-d, M-mode and Doppler examination.

Dr. Damian's December 10, 2000 chart note stated that Plaintiff's catheterization

revealed that his disease had progressed to the point of "total occlusion of the LAD [left

anterior descending artery] with no flow via the graft in that distribution."

On January 11, 2001, Dr. Damian wrote Dr. Poles that Plaintiff had "evidence of progression

of cardiac disease with angina induced by stress and anxiety and difficulty in documenting

objectively the presence of active cardiac disease with a treadmill stress test." 

On January 11, 2001, MetLife notified Plaintiff that benefits under the mental/nervous

provision would be paid to July 29, 2001. MetLife requested any information that supported

a physical condition that would prevent Plaintiff from working at any occupation.

Plaintiff provided MetLife with Dr. Damian's letter dated January 22, 2001 stating that

Plaintiff had "developed symptoms of exertional angina and chest discomfort associated with

hypertension" which was mostly associated "with periods of anxiety, stress and anger related

to his communications with the insurance company regarding his disability policy." Dr.

Damian wrote that “[i]t is clear that any work related interaction, stress, or anxiety does

cause [Plaintiff] profound symptoms and elevated blood pressure which are known to cause

plaque rupture, vasoconstriction, and progression of disease.” Dr. Damian indicated that a

recent catheterization had documented the progression of aggressive cardiac disease as

described in the letter. Dr. Damian expressed the opinion that Plaintiff was at “a very high

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risk” for progression of disease and he should be on total disability while attempting to

control such progression. 

In a February 20, 2001 office note, Dr. Damian reported that Plaintiff had some

“atypical episodes of chest pain which are probably musculoskeletal ... without any evidence

of congestive heart failure.” 

Plaintiff’s pre-termination of benefits appeal was received by MetLife on February

26, 2001. In March 2001, MetLife requested additional information/medical records from

Dr. Damian and from two of Plaintiff's medical providers. 

On March 20, 2001, Dr. Damian reported that Plaintiff had presented with atypical

chest pain, mostly on the right side associated with stress and anxiety related to his father’s

illness. Dr. Damian did not believe that Plaintiff was exhibiting the presence of new

progressive coronary artery disease. On March 29, 2001 Plaintiff underwent a Nuclear Stress

Test at Dr. Damian's office. The test revealed normal cardiac function and excellent exercise

capacity. Dr. Damian's April 2, 2001 office visit note reported that the 24-hour Holter

monitor test was unremarkable, with excellent exercise capacity and absence of myocardial

ischemia. On April 9, 2001, Dr. Damian wrote Dr. Poles that Plaintiff continues to have

atypical but persistent chest discomfort and that there was evidence of residual LAD disease.

Dr. Damian recommended a PTCA/stent. On April 19, 2001, Plaintiff underwent an

angioplasty and stent surgery. 

On April 12, 2001, MetLife referred Plaintiff’s medical records for a Physician

Consultant Review by Amy Hopkins, M.D., MPH, Ph.D. (Board Certified in Internal

Medicine and Occupational Medicine, Fellow of the American College of Occupational and

Environmental Medicine). Dr. Hopkins reviewed the medical records of Drs. Poles, Damian

and Boyer. Dr. Hopkins expressed the opinion that Plaintiff had developed a host of

psychological problems following his heart surgery in January 1999 but that his blood

pressure recordings since early 2000 had been within normal limits. Plaintiff's cholesterol

and two stress tests also were within normal limits. However, a recent cardiac [catheter] had

shown progression of disease "which is to be expected." Dr. Hopkins noted that Plaintiff has

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had atypical chest pain which has not been documented to be of cardiac origin and that

Plaintiff's daily exercise included walking, swimming and golfing. Dr. Hopkins also noted

that Dr. Poles does not feel that Plaintiff had significant limitation and that Plaintiff had not

worked since April 1999 so it could not be presumed that working per se would increase his

blood pressure. Dr. Hopkins found no documented indication of a "cause and effect"

relationship between Plaintiff's working and elevated blood pressure, noting that Plaintiff’s

blood pressure had been well controlled since starting a beta blocker and he had not

attempted work since starting his current medication regimen.

 Dr. Hopkins mentioned that Plaintiff's stress at work increased his cholesterol but "no

such relationship between stress and cholesterol levels has been documented in the medical

literature" and that "stress does not cause, exacerbate, or accelerate [coronary artery

disease]." Dr. Hopkins noted that Plaintiff had held leadership and committee roles in

various organizations, performed volunteer work and functioned adequately outside the

home. Dr. Poles also had recommended that Plaintiff was capable of performing at a medium

work capacity physically. Dr. Hopkins' final recommendation was that no physical

impairments had been documented which preluded Plaintiff from returning to work full time

as to any occupation up to and including medium work capacity.

Plaintiff contends that Dr. Hopkins’ findings that his blood pressure readings and

other tests since early 2000 had been normal were erroneous because she did not have all of

his medical records. According to Plaintiff, in the summer and fall of 2000 he had

experienced high blood pressure and his November 2000 cardiac catheterization revealed

new arterial blockage. 

On April 19, 2001, MetLife wrote Drs. Poles and Damian advising that Plaintiff was

being paid LTD benefits under a mental/nervous contractual provision which expired on July

29, 2001. MetLife included Dr. Hopkins’ findings and stated that Drs. Poles and Damian

were being afforded an opportunity to comment.

On April 23, 2001, Dr. Poles responded to MetLife regarding Dr. Hopkins’

evaluation. Dr. Poles stated that, although Dr. Hopkins’ evaluation of Plaintiff’s physical

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problems was correct, Plaintiff could not psychologically return to his previous occupation

and that attempts at doing so would precipitate chest pain, anxiety, and total dysfunctionality.

Dr. Poles stated that Plaintiff had residual disease in his left anterior descending artery of at

least 60 to 70 percent. 

On May 10, 2001, Plaintiff advised MetLife that he had undergone an angioplasty and

stent surgery on April 19, 2001. During Plaintiff's May 15, 2001 office visit, Dr. Damian

noted that Plaintiff had had a stent/angioplasty and had "remained free of symptoms since

the procedure [had been] performed.”

 On July 9, 2001, Dr. Damian wrote to MetLife in response to Dr. Hopkins’ review,

stating that he did not totally disagree with Dr. Poles who had indicated that Plaintiff was

capable of performing at a medium work capacity physically. Dr. Damian stated that the

problem was not necessarily Plaintiff's physical condition but his mental condition and his

mental ability to deal with the requirements at work, stress, anxiety, and all in perspective

of what had occurred after his unexpected bypass surgery and progression of disease. Dr.

Damian reported that Dr. Hopkins was incorrect in her assessment that “progression of

cardiac disease can be expected” after bypass surgery. Rather, in his opinion, progression is

generally not expected within the first year or two following bypass surgery in patients as

young as Plaintiff. Dr. Damian noted that Plaintiff’s chest pain had been documented to be

of cardiac origin because it had subsided after the angioplasty and stent replacement. 

On July 18, 2001, MetLife advised Plaintiff that it had reaffirmed the determination

that his disability was a mental/nervous condition and that benefits would expire on July 29,

2001. MetLife explained that Dr. Boyer had provided documentation which supported a

mental condition and therefore benefits had been paid on that condition. The letter further

explained that Plaintiff’s doctors and MetLife’s independent physician consultant had

seemed to agree that while Plaintiff has a cardiac condition, it did not physically restrict or

limit Plaintiff’s function as to preclude his ability to return to his former occupation or other

occupation up to a medium level of work capacity. Plaintiff was advised of his appeal rights

in this letter. 

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On July 19, 2001, Plaintiff submitted a letter from Dr. Damian dated July 18, 2001 to

MetLife. Dr. Damian stated in this letter that, post bypass graft surgery, Plaintiff had been

documented to have progressive symptoms of depression and anxiety consistent with wellestablished syndrome. Plaintiff's physical and emotional conditions were jointly contributing

to his progressive cardiac disease and inability to control Plaintiff's blood pressure had been

documented. Dr. Damian opined that Plaintiff was disabled from working in his own

profession or any other profession involving stressful conditions and that if Plaintiff

disregarded his doctors’ recommendations not to work, he faced “reasonably certain untimely

demise.” Dr. Damian observed that anxiety and emotional stress had been documented in

the medical literature since 1994 as a trigger causing disruption of plaque and progressive

occlusive disease. According to Dr. Damian, returning Plaintiff to his working environment

in his profession or any occupation involving stress would start a “cascade of uncontrolled

events that [would] culminate in uncontrolled hypertension as proven before, secondary and

related anxiety and significant disruption of the plaque with fatal outcome.” 

On July 20, 2001, Plaintiff requested another appeal and MetLife referred the claim

to Dr. Hopkins for review. Dr. Hopkins conducted a second Physician Consultant Review

on August 2, 2001. Dr. Hopkins found that Dr. Damian had not provided any additional

information substantiating that Plaintiff had a physical impairment that would prevent him

from working in any occupation. Dr. Damian further had indicated that the primary problem

was Plaintiff’s psychological problems. Dr. Hopkins concluded that no physical impairments

had been documented that would preclude Plaintiff from returning to work full time in any

occupation up to and including a medium work capacity.

On August 3, 2001, Plaintiff’s file was referred to MetLife’s Appeals Department.

On September 12, 2001, Plaintiff’s attorney provided additional medical records from

Plaintiff's primary doctors plus records related to Plaintiff's April 19, 2001 hospitalization

for angioplasty and stent surgery. The file and additional medical records were sent to Dr.

Hopkins for another review. On September 28, 2001, Dr. Hopkins concluded that Plaintiff

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was not precluded by documented physical impairments from returning to work full time up

to and including medium work capacity, stating as follows:

[Plaintiff] has had atypical [chest pain] of long-standing

duration, but it has not been documented to be of cardiac origin.

He has not had any CHF [chronic heart failure], significant

arrhythmias, or ongoing ischemia. [Plaintiff’s] documented

[blood pressures] in the additional information provided were all

[within normal limits], so Dr. Damian’s contention that

[Plaintiff] has uncontrolled [hypertension] is simply not

supported by his own records. It is not clear why he would be

refuting his own [blood pressure] measurements. While

[Plaintiff] may have progressive [coronary artery disease], he

does not have any [symptoms] referable to the cardiac system,

and there is no documented cardiac reason why he cannot

[return to work] in any occupation at up to a medium level work

capacity, at least ... [Plaintiff] clearly had problems w/ stress and

anxiety ... It is not clear why, if Dr. Damian feels that stress is

such a potentially lethal problem in [Plaintiff’s] life, he has not

referred [Plaintiff] to some kind of stress management

program.... The determination of impairment is based upon an

individual’s current condition, not on what might or might not

potentially happen in future situations. While [Plaintiff’s]

anxiety might be impairing him from certain kinds of work, that

cannot be construed as implying that his cardiac condition

would worsen if he returned to work ... No physical impairments

have been documented which preclude [Plaintiff] from [return

to work], [full time], any occupation, at up to and including a

medium work capacity.

On October 10, 2001, MetLife wrote to Plaintiff’s attorney explaining that the

decision had been upheld on appeal. MetLife stated that “[a]fter [Plaintiff’s] bypass surgery,

Dr. Damian and Dr. Boyer indicated that [Plaintiff] regained the physical capacity to perform

sedentary work, but was disabled from his own occupation as a result of a mental health

condition.” The reviewer concluded that Plaintiff was not physically disabled as of July 29,

2001 from performing sedentary-like duties of his own occupation and that there was no

“objective information” in the record showing that “exposure to work stress represents a

severe threat to [Plaintiff’s] physical health.” The letter stated that “in determining disability,

we base our decision on an individual’s current functionality rather than what could

potentially happen in the future.” On October 10, 2001, MetLife informed Plaintiff's

employer that review of Plaintiff's appeal had been completed and that the decision to

terminate benefits had been upheld.

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II.

Standard of Review on Summary Judgment.

A motion for summary judgment may be granted only if the evidence shows "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). To defeat the motion, the non-moving

party must show that there are genuine factual issues "that properly can be resolved only by

a finder of fact because they may reasonably be resolved in favor of either party." Anderson

v. Liberty Lobby, Inc., 477 U.S. 242, 250, 106 S.Ct. 2505, 2511 (1986). The party opposing

summary judgment "may not rest upon the mere allegations or denials of [the party's]

pleadings, but ... must set forth specific facts showing that there is a genuine issue for trial."

Rule 56(e). See also, Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586-

87, 106 S.Ct. 1348, 1356 (1986). 

 III.

Discussion. 

Plaintiff contends that benefits were wrongfully terminated on July 29, 2001 based

on the following arguments: (1) the "mental illness" language of the type used in the Plan

cannot be applied to cases involving mental conditions resulting from physical disorders; (2)

he suffers from both aggressive coronary artery disease and maladaptive personality patterns

and therefore benefits are payable for a physical, not mental, disability; (3) the Plan's

disposition contravened its own interpretation that a claimant is not limited to 24 months of

benefits if he is disabled by a combination of mental and physical ailments which is the case

here. Plaintiff argues that in light of the undisputed documented evidence, he suffers from

coronary artery disease and that he is disabled as a result of a rapidly deteriorating heart

condition in conjunction with his physiologic reaction to job stress. 

Defendants contend that based on the undisputed evidence provided by Plaintiff's

treating physicians, but for Plaintiff's psychological conditions, i.e., bypass anxiety disorder,

Plaintiff would not have any disabling symptoms. Defendants further contend that the

evidence supported by the administrative record shows that Plaintiff has fully recovered from

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his heart surgery, he suffers from a psychological condition, and therefore MetLife's

termination of benefits based on the mental/nervous limitation was proper.

This Court's review of Defendants' decision to terminate benefits is de novo. The

district court, in applying the de novo standard of review, must review de novo the plan

administrator's decision to deny benefits. Tremain v. Bell Industries, Inc., 196 F.3d 970, 978

(9th Cir. 1999). Federal courts apply federal common law when faced with questions of

policy interpretation under ERISA. Padfield v. AIG Life Ins. Co., 290 F.3d 1121, 1125 (9th

Cir. 2002). Under this federal common law, the terms of a plan are given their ordinary and

popular meaning as would a person of average intelligence and experience. Id. A de novo

review "'gives no deference at all' to the decisions of insurers to deny benefits." Kearney v.

Standard Ins. Co., 175 F.3d 1084, 1090 n.2 (9th Cir. 1999). Upon conducting de novo review,

the district court may decide the case on summary judgment if appropriate. Tremain, 196

F.3d at 978.

In order to receive LTD benefits under the Plan, a claimant must be "unable to

perform any and every duty of [the claimant's] own occupation due to a medically determined

physical or mental impairment caused by sickness, disease, [or] injury ..." The claimant also

must be under the regular care and attendance of a doctor. The Plan further provides that if

a claimant is disabled due to "mental illness," benefits are limited to 24 months if treatment

is rendered on an outpatient basis. The term "mental illness" is defined as "a mental,

emotional or nervous condition of any kind." Evidence in the administrative record shows

that Plaintiff is under the regular care and attendance of his physicians following his coronary

artery bypass surgery in January 1999. The parties do not appear to dispute a finding on this

issue in their briefing. 

Based on Plaintiff's view of the medical evidence, Plaintiff has a history of

hypertension (high blood pressure), high cholesterol and coronary artery disease. In January

1999, at age of 51, he underwent four-vessel coronary artery bypass surgery. Although his

prognosis for recovery was "excellent," shortly after surgery, Plaintiff began to experience

exaggerated anxiety resulting in a subsequent diagnosis of "post bypass anxiety syndrome"

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in April 1999. Between April and June 1999, Plaintiff attempted to work at his own

occupation of accountant but it appears that stress related to his job was contributing to his

condition. In June, 1999, Plaintiff's physician Dr. Damian expressed the opinion that "part"

of Plaintiff's symptoms were related to intermittent hypertension. Plaintiff's hypertension was

documented about this same time. In November 1999, Dr. Damian noted that Plaintiff had

slight limitations regarding his cardiac functions, marked limitations with his psychological

functions and that he suffered from post-bypass anxiety syndrome and hypertension. Dr.

Damian expressed the opinion that Plaintiff was unable to engage in gainful activity. During

this same time, Dr. Boyer expressed the opinion that Plaintiff’s acute anxiety and depression

might abate but not his underlying psychophysiologic vulnerability, that is, significant blood

pressure increases when under stress due to his cardiovascular condition. 

A year later, in December 2000, Plaintiff's catheterization revealed that his coronary

artery disease/heart condition had progressed to the point of "total occlusion of the [left

anterior descending artery] with no flow via the graft in that distribution." Dr. Damian's

January 2001 letter to Dr. Poles reported that Plaintiff had "evidence of progression of

cardiac disease with angina induced by stress and anxiety." On January 22, 2001, Dr.

Damian wrote that Plaintiff had developed symptoms of exertional angina and chest

discomfort associated with hypertension which was mostly associated with periods of

anxiety, stress and anger. Dr. Damian also wrote that Plaintiff was at a "very high risk" for

progression of disease. In April 2001, Plaintiff underwent an angioplasty and stent surgery.

In July 2001, Dr. Damian disagreed with Dr. Hopkins and advised MetLife that Plaintiff’s

progressive cardiac disease was not expected. He also stated that Plaintiff’s chest pain had

been documented to be of cardiac origin because it had subsided after the April 2001 stent

surgery. According to Dr. Damian, Plaintiff's progression of cardiac disease with angina

induced by stress and anxiety had been difficult to detect with a treadmill stress test.

Plaintiff's treating physicians have expressed the opinion that Plaintiff is unable to

return to his own occupation or any profession and is totally disabled. In June and November

1999, Dr. Damian recommended Plaintiff's total disability. In January 2001, Dr. Damian

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recommended to MetLife that Plaintiff should be on total disability while attempting to

control the progression of his disease. In April 2001, Dr. Poles wrote to MetLife that Plaintiff

could not psychologically return to his previous occupation and that attempts at doing so

would precipitate chest pain, anxiety and total dysfunctionality. Dr. Poles noted that Plaintiff

had residual disease in his left anterior descending artery of at least 60 to 70 percent. In a

letter dated July 2001, Dr. Damian wrote to MetLife that Plaintiff had physical and emotional

conditions that jointly were contributing to his progressive cardiac disease, again noting

inability to control Plaintiff's hypertension. Dr. Damian opined that Plaintiff was disabled

from working in his own profession or any other profession involving stressful conditions

and that Plaintiff’s return to work would endanger his health. 

In contrast, Defendants have cited medical evidence of record which they claim

indicates that Plaintiff does not have a physical condition that precludes his return to work.

This medical evidence includes a treadmill stress test in March 1999 that revealed normal

results, with no subjective or objective evidence of coronary artery disease. In April 1999,

Dr. Boyer diagnosed Plaintiff as suffering from post bypass anxiety syndrome. In June 1999,

Dr. Damian noted that Plaintiff was struggling with anxiety. An EKG in June 1999 was

unremarkable. In October 1999, Dr. Poles informed MetLife that Plaintiff's problems were

anxiety related not due to physical limitations. Dr. Poles expressed a similar opinion in May

2000. The record medical evidence contains several references to Plaintiff's excellent

exercise capacity. There further were instances of chest pain that did not appear to be cardiac

of origin. In January 2000, Dr. Damian wrote that the objective treadmill stress data

suggested an adequate surgical result and presumed no limitation on Plaintiff's return to

work. In April 2001, Dr. Hopkins in her first review of Plaintiff's medical records noted that

Plaintiff had experienced atypical chest pain which had not been documented to be of cardiac

origin and that Plaintiff's daily exercise included walking, swimming and golfing. Dr.

Hopkins further noted that Dr. Poles had recommended that Plaintiff was capable of

performing at a medium work capacity physically. 

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In July 2001, Dr. Damian wrote MetLife that he did not disagree with Dr. Poles who

had indicated that Plaintiff was capable of performing at a medium work capacity physically.

Dr. Damian stated that Plaintiff's problem was not necessarily his physical condition but his

mental condition and his mental ability to deal with the requirements of work, stress, anxiety,

in perspective of what had occurred after his bypass surgery and progression of disease. In

Dr. Hopkins' second review in August 2001, she concluded that Plaintiff's physicians had not

provided any additional information that substantiated that Plaintiff had a physical

impairment that would prevent him from working in any occupation. Even after Plaintiff

provided additional medical records, including records from his hospitalization for

angioplasty and stent surgery, Dr. Hopkins in September 2001 again concluded upon a third

review that Plaintiff was not precluded from documented physical impairments from

returning to work full time up to and including medium work capacity. In this third review,

however, Dr. Hopkins recognized that Plaintiff "may have" progressive coronary artery

disease. Dr. Hopkins further reported that Plaintiff had no symptoms referable to the cardiac

system and that there was "no documented cardiac reason" why Plaintiff cannot return to

work. 

The issue is whether Plaintiff suffers from a condition, or a combination of

conditions, and whether, as a result, Plaintiff is disabled in the sense defined by the Plan.

Evidence such as that provided from Plaintiff's physicians, including Dr. Damian, could

justify the trier of fact in concluding that Plaintiff's heart condition or coronary bypass

surgery caused his exaggerated mental condition; or, that Plaintiff suffers from a combination

of impairments, and that he is unable to work and is disabled. On the other hand, such

evidence as that provided by Dr. Hopkins could justify the trier of fact in concluding that

Plaintiff's mental condition, that is, his exaggerated anxiety, has rendered him unable to work

but his physical condition, that is, his progressive coronary disease or hypertension, has not.

In other words, Plaintiff does not suffer from a physical condition that renders him totally

disabled and precludes him from working. 

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In addition, the Ninth Circuit has recognized that words such as "mental impairment"

and "mental disorder" as used in Plan provisions may be ambiguous. For example in Kunin

v. Benefit Trust Life Insurance Company, 910 F.2d 534, 541 (9th Cir. 1990), the Plan

contained no definition or explanation of the term "mental impairment" and offered no

illustration of the conditions that are included or excluded. In Patterson v. Hughes Aircraft

Co., 11 F.3d 948 (9th Cir. 1993), the Ninth Circuit found the undefined Plan term "mental

disorder" ambiguous in two ways: (1) the Plain did not specify whether a disability is to be

classified as "mental by looking to the cause of the disability or to its symptoms"; (2) the

Plan did not make clear whether a disability qualified as a "mental disorder" when it results

from a combination of physical or mental factors. Id., at 950. To the extent that a Plan term

is ambiguous, it must be construed against the Plan and in favor of the insured. Lang v.

Long-Term Disability Plan of Sponsor Applied Remote Technology, Inc., 125 F.3d 794, 799

(9th Cir. 1997). In this case, the Plan defines "mental illness" as a "mental, emotional or

nervous condition of any kind". 

Plaintiff and Defendants each have argued that the undisputed facts support entry of

summary judgment in that party's favor. Based on the contradicting medical opinions as to

Plaintiff's condition and alleged disability, there are genuine issues of material so as to

preclude summary judgment. The parties' cross-motions for summary judgment are denied.

"To evaluate Plaintiff's claim, the Court must conduct a bench trial based on the

administrative record and such other evidence as the Court admits." Sabatino v. Liberty Life

Assurance Company of Boston, 286 F. Supp. 2d 1222, 1229 (N.D.Cal. 2003)(citing Kearney

v. Standard Ins. Co., 175 F.3d 1084, 1094-95 (9th Cir. 1999)) In a trial on the record in an

ERISA case, "the judge can evaluate the persuasiveness of conflicting testimony and decide

which is more likely true." Kearney, 175 F.3d at 1094. The trial court "consider[s] anew

both the legal and factual aspects of [the plaintiff's] claim." Thomas v. Oregon Fruit Products

Co., 228 F.3d 991, 995 (9th Cir. 2000).

"A district court, when exercising de novo review of an ERISA benefits denial

decision, may admit additional evidence when 'circumstances clearly establish that additional

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evidence is necessary to conduct an adequate de novo review of the benefit decision.'"

Friedrich v. Intel Corp., 181 F.3d 1105, 1111 (9th Cir. 1999)(quoting Mongeluzo v. Baxter

Travenol Long Term Disability Benefit Plan, 46 F.3d 938, 944 (9th Cir. 1995)). The Court

has determined that additional evidence is necessary to conduct an adequate de novo review.

The additional evidence that will be considered by the Court is the testimony of Defendants'

officials and employees that if the claimant is disabled by both mental and physical

conditions, though neither alone is disabling, benefits are payable beyond the 24-month

period as stated in the Plan for "mental illness." 

The Court will expedite trial of this matter on the administrative record. Defendants

shall file the entire administrative record by April 17, 2006. The parties shall file proposed

findings of fact and conclusions of law by May 5, 2006. The Court will hold a status hearing

to discuss the need for further proceedings in this case. 

Accordingly,

IT IS ORDERED that Plaintiff's motion for summary judgment (Doc. 61) is denied.

IT IS FURTHER ORDERED that Defendants' cross-motion for summary judgment

(Doc. 60) is denied.

IT IS FURTHER ORDERED that Defendants shall file the entire administrative

record by April 17, 2006. 

IT IS FURTHER ORDERED that the parties shall file proposed findings of fact and

conclusions of law by May 5, 2006. 

DATED this 31st of March, 2006.

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