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Allen Marden v. Metropolitan Life Insurance Company

June 5, 2012

ALLEN MARDEN, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Daniel L. Hovland, District Judge United States District Court

ORDER GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT

Before the Court is the defendant Metropolitan Life Insurance Company's motion for summary judgment filed on March 9, 2012. See Docket No. 27. The plaintiff, Allen Marden, filed a response in opposition to the motion on April 13, 2012. See Docket No. 34. Metropolitan Life Insurance Company ("MetLife") filed a reply brief on April 27, 2012. See Docket No. 39. For the reasons explained below, the motion is granted.

I. BACKGROUND

Allen Marden began working for BNSF Railways ("BNSF") on April 28, 1972. His final title was Terminal Manager. MetLife issued a Long Term Disability Insurance plan ("the Plan") to BNSF employees. The plan is governed by the Employee Retirement Income Security Act ("ERISA").

A. TERMS OF THE PLAN

The Plan provides that MetLife reviews claims upon submission. If MetLife denies a claim, an employee can appeal the decision. The appeal is also decided by MetLife. Under ERISA, if an employee believes that MetLife has misused the Plan's money, the employee can file suit in federal court.

The Plan provides, in pertinent part:

In order to receive benefits under This Plan, you must provide to us at your expense, and subject to our satisfaction, all of the following documents. These are explained in this Certificate. Initial submission of these documents should be made no later than the 12th week following your original date of disability.

T Proof of Disability.

T Evidence of continuing Disability.

T Proof that you are under the Appropriate Care and Treatment of a Doctor throughout your Disability.

T Information about Other Income Benefits.

T Any other material information related to your Disability which may be requested by us. . . .

A. Monthly Benefit

You will be paid a Monthly Benefit, in accordance with Plan Highlights, if we determine that:

1. you are Disabled; and

2. you became Disabled while covered under This Plan. . . .

When Benefits End Monthly Benefits will end on the earliest of the following dates: . . .

2. the end of the period specified in the Limitation for Disabilities Due to Particular Conditions and the Limitation For Alcohol, Drug or Substance Abuse or Dependency;

Definition of Disability

"Disabled" or "Disability" means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate care and Treatment from a Doctor on a continuing basis; and

3. During the first 24 months, including your Elimination Period, due to your inability to perform the duties of your Own Occupation you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own Occupation for any employer in your Local Economy; or

4. after the first 24 month period, due to your inability to perform the duties of any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Predisability Earnings, you are unable to earn more than 60% of your Indexed Predisability Earnings from any employer in your Local Economy.

Limitation For Disabilities Due to Particular Conditions You are covered for 24 months of Disability during your lifetime if you are Disabled due to a: . . .

2. Neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:

a. seropositive arthritis;

b. spinal tumors, malignancy, or vascular malformations;

c. radiculopathies;

d. myelopathies;

e. traumatic spinal cord necrosis; or

f. myopathies.

Glossary of Terms Used in This Section . . .

Spinal: Components of the bony spine or spinal cord. . . .

Radiculopathies: Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.

Myelopathies: Disease of the spinal cord supported by objective clinical findings of spinal cord pathology. . . .

Myopathies: Disease of the skeletal muscle supported by clinical, histological, biochemical and/or electrodiagnostic findings.

See Docket No. 28-3, pp. 64, 67-69, 75-76.

B. MARDEN'S MEDICAL AND CLAIM HISTORY

On August 29, 2006, Marden visited Dr. Anthony Johnson complaining of "severe midline lumbar back pain." See Docket No. 28-3, p. 27. Dr. Johnson noted that Marden was "intact" neurologically and treated the pain as "an exacerbation of a chronic condition." See Docket No. 28-3, p. 27. Dr. Johnson prescribed Lorcet, Flexeril, and ibuprofen and recommended "[n]o work above or below the shoulders or below the waist, no lifting greater than 10 pounds, no walking on uneven ground or crawling, etc. for the next two weeks." See Docket No. 28-3, p. 27.

On September 12, 2006, Marden underwent an MRI. The MRI showed "[m]ild desiccation of the lower three lumbar intervertebral discs. No evidence of disc herniation or lumbar canal stenosis. Verterbral body height, signal, and alignment is normal. Lumbar MRI is otherwise negative." See Docket No. 28-3, p. 29.

Marden visited Dr. Johnson on September 14, 2006. Dr. Johnson determined that Marden had "[b]ack pain with degenerative disk disease of the lower 3 lumbar vertebra." See Docket No. 28-3, p. 25. Dr. Johnson told Marden he may need to consider partial or full disability. He also recommended physical therapy and a referral to anesthesia for injections.

On November 3, 2006, Dr. Johnson advised Marden to find a desk job. He also recommended full or partial disability. Dr. Johnson stated Marden's diagnoses as "[d]isc desiccation with pain and some radiculopathy." See Docket No. 28-3, p. 23. Marden ...


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