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Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 

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United States Court of Appeals

FOR THE EIGHTH CIRCUIT

___________

No. 05-2200

___________

James Seitz, *

*

Plaintiff - Appellant, *

* Appeal from the United States

v. * District Court for the Northern 

* District of Iowa.

* 

Metropolitan Life Insurance Company; *

Merck & Co., Inc., Medical, Dental, *

and Long-Term Disability Program for *

Non-Union Employees, *

*

Defendants - Appellees. *

___________

Submitted: December 2, 2005

 Filed: January 10, 2006 

___________

Before MELLOY, COLLOTON, and BENTON, Circuit Judges.

___________

MELLOY, Circuit Judge.

The district court granted summary judgment for the defendants regarding their

denial of the plaintiff’s claim for disability benefits. We reverse and remand.

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 Because we find that Seitz’s neck and back injuries rendered him totally

disabled–pursuant to the Plan’s definition–and thus entitled to benefits, we need not

discuss the specifics of his depression or any other psychiatric issues. 

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I. Background

James Seitz was a Senior Professional Sales Representative for Merck & Co.,

Inc. (“Merck”). While working at Merck, Seitz was diagnosed with spinal

impairments including spondylosis and degenerative disc disease as well as

depression.1

 When his neck and back injuries progressed, Seitz applied for long-term

disability benefits under Merck’s Medical, Dental, and Long-Term Disability Program

for Non-Union Employees (the “Plan”). Metropolitan Life Insurance Company

(“MetLife”), Merck’s third party disability benefits administrator, refused to approve

payment to Seitz. 

Seitz began to suffer from back pain in 1983. In April 2001, he received a letter

from his treating physician, Dr. Ernest M. Found. Dr. Found stated that upper back

and neck pain resulting from spinal surgeries rendered Seitz incapable of sitting for

long periods or doing more than very occasional reaching, lifting, or working

overhead. On September 12, 2001, Dr. Found again documented Seitz’s physical

limitations, this time in the form of a “physical capacity evaluation.” Dr. Found

reported that Seitz was unable to sit, stand, walk, bend, climb, crawl, reach, kneel,

squat, twist, push/pull, grasp or drive in excess of two hours a day. Seitz continued

to work until January 29, 2002. Shortly before leaving his job, Seitz drove from

Dubuque, Iowa, to Chicago, Illinois, to attend a job training session. The sitting

during the drive to the session and/or during the session aggravated his condition. 

On May 24, 2002, at MetLife’s behest, Merck business manager Candace

Hodge completed a description worksheet for Seitz’s job. Hodge reported that a

normal work day for Seitz required him to sit for five to six hours, stand for one to

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two hours, and engage in extensive walking, bending, twisting, reaching above

shoulder level, crouching/stooping, kneeling, balancing, pushing and pulling. 

On May 29, 2002, Seitz submitted a claim for benefits to the Plan. Under the

terms of the Summary Plan Description (“SPD”), an individual is eligible for Long

Term Disability benefits after that person has been “totally disabled” for the duration

of the Eligibility Period. The SPD has the following description of “totally disabled”:

Totally disabled means you are unable to perform all material aspects of

your occupation during the Eligibility Period and during the first 24

consecutive months that benefits are paid under the Long-Term Disability

Plan. After the first 24 consecutive months of disability, you must be

unable to engage in any Gainful Employment for which you are or may

become reasonably qualified by education, training or experience.

You must be under the regular care of a licensed doctor to be considered

totally disabled. The doctor must also have appropriate expertise for your

disability and you must follow the prescribed course of treatment.

The Eligibility Period is separately defined as: “[a] consecutive 26-week period for

which you have been continuously totally disabled.”

The SPD grants the Plan Administrator the discretion to construe and interpret

the provisions of the Plan; make factual determinations; decide all questions of

eligibility for benefits; resolve issues arising in the administration, interpretation,

and/or application of the Plan; correct any defects; reconcile any inconsistencies; and

supply any omissions with respect to the Plan.

On August 8, 2002, MetLife denied Seitz’s claim. MetLife’s denial letter stated

that Seitz’s medical documentation did not support an impairment severe enough to

preclude him from returning to his own occupation during the Eligibility Period which

began when Seitz ceased working on January 29, 2002. Seitz underwent additional

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diagnostic testing and then appealed MetLife’s decision on October 3, 2002. Seitz

was evaluated by another doctor, E. Richard Blonsky, on October 14, 2002. Dr.

Blonsky reported that Seitz’s “physical condition prohibits him from performing the

activities of his job.” Seitz submitted Dr. Blonsky’s report to MetLife along with

reports of other doctors and a finding by the Social Security Administration that Seitz

qualified for disability benefits. 

MetLife requested an Independent Medical Examination and notified Seitz of

this request in a letter dated December 16, 2002. Seitz’s claim file was sent to Dr. M.

Barry Lipson. Dr. Lipson filed a report in which he agreed with the limitations on

Seitz set forth by Dr. Found. Dr. Lipson also said that work activities would

exacerbate Seitz’s condition and render him “incapable of performing the essential

duties of his job.” 

On February 5, 2003, Seitz commenced this action in the United States District

Court for the Northern District of Illinois seeking the recovery of disability benefits

from an ERISA-governed employee benefit plan pursuant to 29 U.S.C. §

1132(a)(1)(B). MetLife denied Seitz’s appeal for benefits the next day. The letter

denying Seitz’s appeal stated in part:

We do not dispute your client’s diagnosis or complaints. However, as

indicated in the [P]lan, to be considered totally disabled, a claimant must

have continuously been unable to perform all material aspects of his

occupation, not necessarily his own job . . . from January 29, 2002

through July 30, 2002. Dr. Found repeatedly indicated . . . that your

client was capable of light work with restrictions . . . . There is no

indication throughout the documentation from Dr. Found that Mr. Seitz

was informed to cease working as of January 29, 2002. 

On December 22, 2003, Seitz’s case was transferred to the Northern District

of Iowa. On March 30, 2005, the district court granted MetLife’s motion for summary

judgment and denied Seitz’s motion for summary judgment.

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 The letter rejecting Seitz’s appeal also notes that he was not under the regular

care of an appropriate doctor, but the district court rejected this requirement of the

Plan because there was no evidence that additional visits to a doctor would have

improved Seitz’s condition. MetLife does not appeal this determination, and, as such,

we need not address it. 

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II. Standard of Review

We review de novo the district court’s determination of the standard of review

applicable to MetLife’s denial of benefits. Torres v. UNUM Life Ins. Co. of America,

405 F.3d 670, 677 (8th Cir. 2005). Because the Plan gives MetLife the discretionary

authority to determine eligibility for benefits, we find that the district court correctly

reviewed MetLife’s eligibility determination for abuse of discretion. Jackson v.

Metro. Life Ins. Co., 303 F.3d 884, 887 (8th Cir. 2002). We also engage in de novo

review of the district court’s application of the abuse of discretion standard. FletcherMerrit v. NorAm Energy Corp., 250 F.3d 1174, 1179 (8th Cir. 2001). Under the

abuse of discretion standard, we will not disturb an administrator’s decision if the

administrator makes a reasonable interpretation of uncertain terms in a policy, and the

decision based on that interpretation is supported by substantial evidence. King v.

Hartford Life and Accident Ins. Co., 414 F.3d 994, 999 (8th Cir. 2005).

III. Discussion

A. The Benefits Claim

MetLife’s letter denying Seitz’s appeal for long-term disability benefits stated

that “a claimant must have continuously been unable to perform all material aspects

of his occupation, not necessarily his own job, for 26 consecutive weeks.”2

 The only

description of Seitz’s occupation that is before us is the description of Seitz’s job

created by Candace Hodge. This description stated that during a normal workday

Seitz was required to sit for five to six hours. Every doctor that examined Seitz,

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including the independent examiner chosen by MetLife, agreed that Seitz was limited

to sitting for no more than two hours during the day. Thus, Seitz was physically

unable to fulfill at least one material aspect of his job. 

MetLife does not dispute that Seitz was limited to sitting only two hours a day.

Metlife instead argues that, despite the limitation on sitting, Seitz does not meet the

Plan’s definition of “totally disabled.” The district court stated that MetLife’s

argument is that Seitz is not totally disabled because he can do some of the material

aspects of his job. In its brief, MetLife argues that Seitz is not totally disabled because

he can do all of the material aspects of his job, albeit to a limited degree. We reject

both of these arguments. 

We have previously held that when a Plan uses an individual’s own occupation

to determine whether he or she is totally disabled, being able to perform some job

duties is insufficient to deny benefits. See Dowdle v. Nat’l Life Ins. Co., 407 F.3d

967, 971-72 (8th Cir. 2005) (applying Minnesota law and affirming a grant of

summary judgment awarding disability benefits to a surgeon who could perform some

functions of his occupation but could no longer operate on patients); see also Saffle

v. Sierra Pac. Power Co. Bargaining Unit Long Term Disability Plan, 85 F.3d 455,

458 (9th Cir. 1996) (rejecting the insurer’s position that a claimant “is not totally

disabled if she can perform any single duty of her job, no matter how trivial . . . as

‘total disability’ would only exist if the person were essentially non-conscious.”). We

also find unreasonable an interpretation of the Plan that would deny benefits when a

claimant is able to perform all material aspects of his job for some limited period of

time. See McFarland v. Gen. Am. Life Ins. Co., 149 F.3d 583, 588 (7th Cir. 1998)

(holding that a claimant can be totally disabled when “an injury or sickness would not

physically prevent an employee from performing any given task, but the injury instead

renders the person unable to perform enough of the tasks or to perform for a long

enough period to continue working at his regular occupation.”). Seitz’s job required

him to sit for five to six hours per day. Sitting for up to two hours does not fulfill that

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material aspect of the job. Furthermore, these interpretations are not “consistent with

the goals of the Plan” which are “to provide an umbrella of financial protection for

[employees] and [their] famil[ies] against substantial economic loss as well as provide

a level of economic security.” Torres, 405 F.3d at 680 (stating that one of the factors

to be considered in determining if there has been an abuse of discretion is “whether

the administrator’s interpretation is consistent with the goals of the Plan”). 

MetLife asserted two additional rationales as to why it should be allowed to

deny Seitz’s benefits. MetLife argued that Seitz was not totally disabled because he

continued to work after his spinal problems were diagnosed and his condition did not

significantly change between the time of the diagnosis and the day he quit working

and sought benefits. We reject this argument because there is no dispute that Seitz’s

physical abilities were limited at the time he quit working. Thus, adopting MetLife’s

position would unfairly punish individuals who test their limitations and attempt to

keep working before seeking benefits. MetLife also asserted that Seitz exacerbated his

condition by attending an out-of-town job training session. The record is unclear as

to whether Seitz was required to attend this session, but, even if his attendance was

voluntary, it does not affect our analysis. Nothing in the Plan language requires Seitz

to have been injured during the course of his employment. As such, the cause of any

aggravation to his condition is immaterial.

Because we reject MetLife’s stated reasons for denying benefits, and because

there are no outstanding questions of fact regarding Seitz’s medical condition, we find

that Seitz is entitled to summary judgment granting benefits under the Plan.

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B. Interest on the Judgment

Seitz also requests prejudgment interest on the past due benefits. We find that

the benefits were wrongfully delayed, and, thus, prejudgment interest is appropriate

as equitable relief under 29 U.S.C. § 1132(a)(3)(B). Parke v. First Reliance Standard

Life Ins. Co., 368 F.3d 999, 1009 (8th Cir. 2004).

C. Attorneys’ Fees

Seitz also requests an award of his attorneys’ fees. The factors to be used in

considering such a request are: 

(1) the degree of culpability or bad faith of the opposing party; 

(2) the ability of the opposing party to pay attorney fees; 

(3) whether an award of attorney fees against the opposing party might

have a future deterrent effect under similar circumstances; 

(4) whether the parties requesting attorney fees sought to benefit all

participants and beneficiaries of an ERISA plan or to resolve a significant

legal question regarding ERISA itself; and

(5) the relative merits of the parties’ positions.

Martin v. Ark. Blue Cross & Blue Shield, 299 F.3d 966, 969 n.4 (8th Cir. 2002).

Although we disagree with MetLife’s interpretation of the Plan’s language, we do not

find their interpretation to be without merit or a demonstration of bad faith. We also

do not believe the other factors to be of great weight in this case. Accordingly, we

deny Seitz’s request for attorneys’ fees. 

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III. Conclusion

For the foregoing reasons, we reverse the grant of summary judgment for

MetLife and remand for entry of a judgment consistent with this opinion.

______________________________

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