Opinion
Civil Action No: 03-1059, Section: "R".
August 18, 2004
ORDER AND REASONS
This is an action for review of the denial of long-term disability benefits by the administrator of an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1054, et seq. Before the Court are the parties' cross-motions for summary judgment. For the following reasons, the Court GRANTS defendants' motion for summary judgment and DENIES plaintiff's cross-motion for summary judgment.
I. BACKGROUND
Plaintiff, Debora Roig, was employed as a District Sales Manager for Victoria's Secret Stores, Inc. in Louisiana from July 21, 1986 to July 14, 1998. Roig's duties at Victoria's Secret involved, among others, working up to 8-12 hours per day with a one-half to one-hour break; travel on an average of 3-4 days per week; extensive driving to oversee multiple store locations 4-5 times per week; and store maintenance. Her job also involved heavy lifting.
As a Victoria's Secret employee, Roig participated in The Limited Long Term Disability Program ("the Plan"), an employee welfare benefit plan governed by the Employee Retirement Income Security Act ("ERISA"). The Limited, Inc. self-funded the Plan, and the Limited Associate Benefits Committee served as the Plan Administrator. Under an Administrative Services Agreement, the Limited contracted with Metropolitan Life Insurance Co. ("MetLife") to serve as Claims Administrator. The Limited delegated to MetLife the responsibility and discretionary authority for determining eligibility for disability benefits, construing Plan terms, and providing a full and fair review of determinations in connection with the appeal of claims denied. MetLife did not insure and was not liable for the Plan benefits.
The Plan provides two types of benefits: 1) those paid during the first twelve months of disability ("initial benefits"); and 2) those paid beyond the first twelve months ("long-term" benefits). The Plan establishes different criteria for each type of benefit.
In September 1995, Roig was involved in an automobile accident. Approximately one year later, she sought treatment at a local medical center for low back pain and occasional leg pain and numbness. The attending physician diagnosed Roig with a moderately herniated disc and degenerative disc disease. Roig saw Thomas P. Perone, M.D. for a neurosurgical evaluation. After examining Roig on June 1, 1998, Dr. Perone noted improvement in the herniated disc. Despite the improvement, he concluded that the Roig could no longer physically do the requirements of her job due to the extensive travel it required.
On June 15, 1998, Roig saw Dr. Perone again and told him that she had fallen that morning, striking her left knee and further injuring her back. Dr. Perone noted that although Roig's herniated disc had resolved with conservative measures, she still suffered from significant degeneration of the bottom three discs in her lumbar spine. As a result of this degenerative condition of her spine, Dr. Perone recommended that Roig permanently avoid activities that were an integral part of her job.
On July 13, 1998, Roig stopped working at Victoria's Secret. She submitted an application to MetLife for disability benefits on August 1, 1998. MetLife denied Roig's claim for benefits on August 27, 1998. Roig requested a review of the denial of her benefits on September 15, 1998. After review, MetLife again denied Roig's claim for benefits on January 18, 1999.
On August 12, 1999, Roig filed suit in this Court against MetLife and the Plan for failure to pay benefits and breach of fiduciary duties under ERISA, Civil Action No. 99-2460. The parties submitted the case on the record to this Court for a bench trial. This Court found that MetLife was not a proper party to the suit and dismissed it from the proceedings. The Court awarded Roig initial benefits but denied long-term benefits because the record lacked evidence to support them. Roig appealed this Court's denial of long-term benefits, and the Plan cross-appealed this Court's grant of initial benefits. In an opinion dated October 9, 2001, the Fifth Circuit affirmed the grant of initial benefits and reversed the denial of long-term benefits. The Fifth Circuit concluded that because the plan administrator denied initial benefits, it did not reach the issue of long-term benefits and this Court should have remanded the case to the administrator to determine whether Roig is entitled to long-term benefits. This Court remanded the case to the administrator to conduct further proceedings consistent with the Fifth Circuit's opinion.
Defendant asserts that MetLife commenced its review of Roig's claim for long-term benefits on December 12, 2001. MetLife sent a letter to Roig that requested copies of her medical records from all of her treating physicians since July 14, 1999. Def.'s Memo. in Opp. to Pla.'s Mot. in Limine, Ex. 1 at LTD-314. The letter indicated that after MetLife received the medical records, it would schedule her for an Independent Medical Examination (IME). Id. Roig sent MetLife a letter dated February 8, 2002 with the requested information. MetLife scheduled Roig for a Functional Capacity Examination (FCE) on July 15-16, 2002. She completed the first day of testing but did not complete the second day of testing due to complaints of pain. On September 17, 2002, MetLife requested that the Roig submit to an IME, which was performed October 16, 2002.
MetLife denied Roig's claim for long-term benefits on January 2, 2003. Id. at LTD-094-96. Roig submitted additional information to MetLife in January and indicated her intent to request an appeal. Id. at LTD-090-91. Roig formally requested an appeal in a letter dated February 25, 2003. Id. at LTD-077. Defendant asserts that MetLife received the request on March 3, 2003. In a letter dated March 4, 2003, MetLife advised Roig that her claim had been referred to an independent panel for review and that MetLife would evaluate the panel's findings and advise her of its final determination within 45 days. Id. at LTD-076. MetLife noted that the review may take up to an additional 45 days if special circumstances existed that required additional time. Id. On April 15, 2003, 43 days after MetLife received Roig's formal appeal request, Roig filed this suit, in which she alleged that MetLife had constructively denied her claim and thus all of her administrative remedies had been exhausted. MetLife notified Roig on April 22, 2003, that it would require an additional 45 days to render a decision on her appeal. MetLife affirmed its denial of benefits on August 7, 2003.
II. DISCUSSION
A. Legal Standard
Summary judgment is appropriate when there are no genuine issues as to any material facts, and the moving party is entitled to judgment as a matter of law. See FED. R. CIV. P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322-323 (1986). A court must be satisfied that no reasonable trier of fact could find for the nonmoving party. Lavespere v. Niagara Mach. Tool Works, Inc., 910 F.2d 167, 178 (5th Cir. 1990). The moving party bears the burden of establishing that there are no genuine issues of material fact.
If the dispositive issue is one on which the nonmoving party will bear the burden of proof at trial, the moving party may satisfy its burden by pointing out that the evidence in the record contains insufficient proof concerning an essential element of the nonmoving party's claim. See Celotex, 477 U.S. at 325; see also Lavespere, 910 F.2d at 178. The burden then shifts to the nonmoving party, who must, by submitting or referring to evidence, set out specific facts showing that a genuine issue exists. See Celotex, 477 U.S. at 324. The nonmovant may not rest upon the pleadings, but must identify specific facts that establish a genuine issue exists for trial. See id. at 325; Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1996).
B. ERISA Review
Under ERISA, a claims administrator must make two findings to determine whether an employee is entitled to benefits under a plan. Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 394 (5th Cir. 1998) (citing Pierre v. Conn. Gen. Life Ins., 932 F.2d 1552, 1557 (5th Cir. 1991)). 1557). The administrator must first determine the facts underlying the claim for benefits. Id. (citing Pierre, 932 F.2d at 1562). The administrator must then "determine whether those facts constitute a claim to be honored under the terms of the plan." Id. (emphasis in original). If the administrator denies benefits to the participant, section 1132 of ERISA provides that the employee may bring suit in federal district court "to recover benefits due to him under the terms of the plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). With these basic principles in mind, the Court reviews MetLife's factual and interpretative decisions.
1. Review: Findings of Fact
a. Standard of Review
The Fifth Circuit has held that the district court should review a claims administrator's determination of the facts underlying the claim for an abuse of discretion. Schadler, 147 F.3d at 395 (citing Pierre, 932 F.2d at 1562). Roig concedes that abuse of discretion is the typical standard, but argues that the Court should review the claims administrator's determination either de novo or with less deference because of conflict of interest or bad faith. Pla.'s Cross Mot. Summ. J. at 4. Thus, the Court will determine the extent to which Roig has proved bad faith or a conflict of interest before reviewing the determination.
As to Roig's conflict of interest claim, even if an administrator has operated under a conflict of interest, de novo review is never the appropriate standard under which to review a determination made by an administrator with discretionary authority. See Vega v. Nat'l Life Ins. Services, 188 F.3d 287, 296-97 (5th Cir. 1999) (considering and rejecting de novo review of conflicted administrators' determination). The appropriate standard under which to review a conflicted claims administrator's determination is abuse of discretion, considering the administrator's conflict as a factor in the court's determination. Vega, 188 F.3d at 297. "The greater the evidence of a conflict on the part of the administrator, the less deferential [the] abuse of discretion standard will be." Id.
As the Court found in Roig I, MetLife did not operate under a conflict of interest. 2000 WL 1146522 at *11 (E.D. La. 2004). A claims administrator operates under a conflict of interest when it can profit from a decision to deny benefits. This could occur, for example, when the plan insurer and the claims administrator are the same entity. Vega, 188 F.3d at 295. See also Lain v. UNUM Life Ins. Co. of Am., 279 F.3d 337, 343 (5th Cir. 2002) (recognizing conflict of interest where claims administrator was also the insurer); Gooden v. Provident Life and Acc. Ins. Co., 250 F.3d 329, 333 (5th Cir. 2001) (same); Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 599 (5th Cir. 1994) (same); Duhon v. Texaco, Inc., 15 F.3d 1302, 1305 (5th Cir. 1994) (same). MetLife is the claims administrator, but there is no evidence that MetLife is the plan insurer. Indeed, Roig does not even assert that Metlife is the plan insurer. Moreover, Roig has failed to demonstrate how MetLife could otherwise profit from a decision to deny benefits. Upon review of the record, the Court is unable to find evidence of a conflict. Thus, the Court rejects Roig's claim that the standard of review should be more stringent because MetLife operated under a conflict of interest.
Roig also asserts that MetLife acted in bad faith, so that its decisions deserve a less deferential review. The Court finds that Roig fails to establish that MetLife acted in bad faith. First, Roig points to the grounds on which this Court found an abuse of discretion in Roig I and asserts that they demonstrate bad faith. Roig does not offer anything more in connection with those grounds. The Court's earlier finding of abuse of discretion, without more, indicates only that the administrator abused its discretion in making its judgment. It does not indicate bad faith per se. Nor does Roig offer any other evidence of bad faith. Her conclusory characterization of Metlife's decision as "blatantly wrong" falls short of the mark.
The Court finds that Roig has not shown the existence of bad faith or conflict of interest. Therefore, the Court will apply the abuse of discretion standard to review MetLife's fact findings.
To decide whether MetLife abused its discretion, the Court must determine if the administrator acted arbitrarily and capriciously when it reached its conclusion as to the facts. Johnson v. Sun Life Assurance Co., 2000 WL 33225469, No. Civ. A. 98-990-A, at *9 (M.D. La. 2000). An arbitrary decision "is one made without a rational connection between the known facts and the decision or between the found facts and the evidence." Id. A decision is not an "abuse of discretion if a reasonable person could have reached a similar decision, given the evidence before him." McCall v. Burlington Northern/Santa Fe Co., 237 F.3d 506, 512 (5th Cir. 2000) (citing Cash v. Wal-Mart Group Health Plan, 107 F.3d 637, 641 (8th Cir. 1997)). Moreover, the Court should review the administrator's fact findings regarding the eligibility of a claimant based on the evidence before the administrator. Schadler, 147 F.3d at 395 (citing Wildbur v. ARCO Chem. Co., 974 F.2d 631, 639 (5th Cir.), modified on other grounds, 979 F.2d 1013 (5th Cir. 1992)). Thus, the Court is confined to the administrative record. For the following reasons, the Court finds that, based on the record before it, MetLife did not abuse its discretion in determining the facts underlying Roig's claim.
b. Roig's Application for Benefits
After reviewing the standard for "Total Disability" under the Plan and the evidence before MetLife, the Court concludes that MetLife did not abuse its discretion when it denied Roig long-term disability benefits.
The plan defines "total disability" as follows:
"Total Disability" means that a participant:
(a) is under the regular care of a physician; and
(b) as a result of an Illness/Injury having an Onset
Date while the Participant is a Participant;
(i) during the twelve (12) months immediately following the Benefit Commencement Date, the participant is unable to perform any and every duty related to the Participant's regular occupation in which he or she was engaged immediately prior to the occurrence of the Illness/Injury;
(ii) thereafter, the Participant cannot work at any gainful occupation for which the Participant is reasonably qualified, or could become qualified, by education, experience or training.
( See Adm. Record at LTD-443). Roig submitted her initial medical disability claim statement on August 1, 1998. Id. at LTD-436. Roig received an initial twelve months of disability benefits for degenerative disc disease and carpal tunnel syndrome under the order of this Court. Id. at LTD-2. She now seeks review of MetLife's denial of long-term disability benefits beyond the initial year of benefits she already received. To be eligible for these benefits, she had to be unable to work at any gainful occupation that she was qualified or could become qualified to perform.
Roig and MetLife compiled the following information to determine Roig's eligibility for long-term disability benefits:
1. Correspondence from Roig's former attending physician, Dr. Perone, to her counsel, dated July 30, 1999; December 3, 1999; and January 5, 2001;
2. Progress Notes from Dr. Perone, from July 30, 1999; August 31, 1999; October 18, 1999; December 3, 1999, December 14, 1999; February 3, 2000; April 5, 2000; April 14, 2000; June 6, 2000; and August 15, 2000;
3. Correspondence from Larry Stokes, Ph.D., a vocational rehabilitation counselor, to Roig's counsel, dated August 26, 1999;
4. Documentation of an Independent Medical Review (IMR) by Clifford Roberson, M.D., dated November 9, 1999; and Dr. Roberson's review of additional information, dated February 4, 2000;
5. Reports of Louis J. Provenza, M.D., Roig's current attending physician, dated December 24, 2001; February 7, 2002; and July 17, 2002;
6. Statement by Roig, dated January 29, 2002;
7. MetLife Personal Profile, dated January 29, 2002;
8. Affidavits by Roig, dated April 3, 2000; and December 20, 1999;
9. Functional Capacity Examination, dated July 17, 2002;
10. Transferable Skills and Labor Market Analysis, dated November 15, 2002;
11. Independent Medical Examination (IME) performed by Ralph Katz, M.D., dated November 15, 2002;
12. Labor Market Survey.Id. at LTD-97 to LTD-371. The information showed that Roig suffered from a degenerative condition of her cervical and lumbar spine and recurring headaches. Id. at LTD-264 to LTD-265.
In his letter to Roig's counsel, dated July 30, 1999, Dr. Perone reported that Roig remained subject to the same limitations to which she had been subject in June 1998. Id. at LTD-265. The specific restrictions Dr. Perone imposed on Roig in June 1998 were that she lift no more than 20 pounds, work no longer than eight hours per day, and drive no longer than one hour without a break. Id. at 397. On August 31, 1999, Dr. Perone noted no change in Roig's condition, save an "improved range of motion of her cervical and lumbar spine." Id. at LTD-264, LTD-261. Roig's attending physicians (first Dr. Perone in December 1999, then Dr. Provenza in 2001) later opined that she was totally disabled from any occupation based primarily on increased subjective reports of pain. See id. at LTD-223 to LTD-224, LTD-237. They did not point to any objective test that revealed a progression in Roig's degenerative disease. During 1999 and 2000, Dr. Perone notes Roig's reports of pain and some limitation of motion, but he repeatedly notes that her gait was normal, her strength intact, and her reflexes were symmetrical. Id. at LTD-246-252, 263-282.
On the other hand, the independent medical examiners found Roig's complaints of pain and disability to be "considerably out of proportion" with the objective evidence. Id. at LTD-320. See also id. at LTD-110. The first independent examiner, Dr. Roberson, performed an IMR of Roig's medical records. He based his conclusions on her medical records from Dr. Perone, including Dr. Perone's radiographic studies. Id. at LTD-367 to LTD-371. Dr. Roberson concluded, based on her radiographic studies, her symptoms, her physical examination and her participation in recreational activity, that "her medical condition is far from disabling." Id. at LTD-320.
The second independent examiner, Dr. Katz, performed an IME on Roig. He based his conclusions on physical examination and x-rays of Roig, her medical records, a letter from Roig's lawyer, and a CD-rom of an interview with Roig. Id. at LTD-104 to LTD-110. He also reviewed Dr. Roberson's reports. Id. at LTD-108. Dr. Katz's examination of Roig noted reports of pain but found that Roig has normal lordosis in the lumbar spine with no palpable tenderness but with signs of guarding. Id. at LTD-109. Her strength was intact and her reflexes were symmetrical. Id. Her x-rays revealed degenerative disc disease. Id. Dr. Katz determined that Roig suffered from chronic pain from degenerative disc disease with no evidence of radiculopathy. Id. at LTD-110. He concluded that she was capable of "some sort of meaningful employment" in a light capacity. Id.
Additionally, Roig completed day one of a two-day FCE. She performed all of the activities on day one with no signs of self-limitation, complaints of pain, or strength defects. Id. at LTD-151. She was able to lift 45 pounds from floor to waist, and 40 pounds from waist to shoulder. Id. She was unable to complete day two of the FCE because of complaints of pain. Id. at LTD-152.
When it denied her claim on January 2, 2003, MetLife informed Roig that "[o]n the basis of the partial FCE and IME findings, you should be able to perform at a sedetary to light occupation." Id. at LTD-95. Sedentary work includes "lifting, carrying, pushing and/or pulling up to 10 pounds occasionally. While sedentary work involves mostly sitting, brief periods of walking or standing may be required." Id. Light work includes "lifting, carrying, pushing and/or pulling up to 20 pounds occasionally and 10 pounds frequently. [It] may also involve walking and/or standing for frequent periods and pushing and/or pulling of arm and/or leg controls." Id. MetLife also conducted a Labor Market Survey and found that sedentary and light occupations for which Roig was qualified existed at competitive pay in Roig's local area. Id.
Based on the information before MetLife, the Court finds that MetLife did not abuse its discretion in determining that Roig was not "totally disabled" after her first year of receiving disability benefits. The restrictions Dr. Perone placed on her in June 1998 and reaffirmed in July 1999 do not support a finding that Roig was totally disabled from any occupation. The opinions of Dr. Katz and Dr. Roberson reasonably support the conclusion that Roig is not totally disabled from any occupation. Therefore, MetLife's conclusion that Roig could work in a light to sedentary occupation and that those occupations were available to Roig was reasonable.
c. Roig's Appeal of MetLife's Denial of Benefits
Roig submitted her appeal on February 25, 2003. Id. at LTD-77 to LTD-80. Roig and MetLife compiled the following information to evaluate her appeal:
1. New report by Dr. Stokes, dated February 24, 2003;
2. Review of Dr. Stokes' findings by rehabilitation counselor Sally McSween, dated June 18, 2003;
3. IMR performed by Marc Soriano, M.D., dated May 7, 2003;
4. Supplemental IMR performed by Dr. Soriano, dated July 28, 2003.
5. Interview with Dr. Provenza
6. Interview with RoigId. at LTD-07 to LTD-14, LTD-59 to LTD-61, LTD-78 to LTD-80, LTD-577, LTD-578. Dr. Stokes affirmed his 1999 opinion that Roig was unable to return to work. Id. at LTD-78 to LTD-80. Dr. Stokes listed the records that he reviewed in making his decision, including office notes, records from MetLife, records from Dr. Katz, and the videotaped interviews with Roig and with Dr. Provenza. Id. at LTD-79. Dr. Stokes noted that he reviewed the information and disagreed with Dr. Katz's conclusion that Roig could work. Id. Dr. Stokes further noted that both he and Dr. Provenza believed that the side effects of Roig's medications impaired her ability to concentrate and pay attention. Id. Dr. Stokes did not refer to any objective medical tests that indicated a worsening in the condition of Roig's back or neck.
After reviewing Roig's records, Dr. Soriano concluded that, regarding her degenerative disc disease, "[t]he history, physical examination, and testing do not support the diagnosis of total disability from her treating physician. There is no evidence of any objective findings and the x-ray findings show simply mild to moderate degenerative changes not inconsistent with normal aging processes." Id. at LTD-17. He found Roig's subjective complaints disproportionate to the objective findings on x-rays and physical exams. Id. at LTD-16, 17. While degenerative disc disease is progressive by nature, MRI findings revealed that "they have remained stable and have not demonstrated any tendency towards acute deterioration or worsening." Id. at LTD-13. Dr. Soriano also evaluated the potential effects of Roig's medications. He concluded that they can cause lethargy or sleepiness, but the body "typically adjusts to [them] and [they do] not produce long-standing inability to function." Id. at LTD-12. He also suggested changes in her medication program that could minimize drowsiness. Id. at LTD-13.
In his interview, Dr. Provenza stated that he last examined Roig on July 17, 2002. Id. at 577. She reported lumbar pain and increased pain with activity. Id. Roig had completed day one of the FCE two days before she saw Dr. Provenza. Id. At that time, Dr. Provenza diagnosed her with acute lumbar spasms. Id. He reported that Roig has pain and degenerative disc disease. Id. Dr. Provenza did not report that he had performed any objective tests on Roig. Id. Instead, he stated that he review prior tests from Dr. Perone. Id. He thought that an MRI had been recommended, but Roig had not had the MRI. Id. He speculated that the MRI would probably show a worsened condition. Id. He reviewed Dr. Katz's report, and he did not know the basis for Dr. Katz's conclusion that Roig was not disabled. Id. Dr. Provenza reported that Roig is on narcotic pain medication, and that he does not recommend that any patient drive when taking narcotic medication. Id. Dr. Provenza's ultimate conclusion was that Roig is disabled and unable to do any type of work. Id.
Roig recounted her experience completing the FCE. Id. at 578. She stated that she felt pressured into cooperating on day one. Id. Roig was unable to complete the second day of the FCE because she was in pain. Id.
Roig argues that MetLife abused its discretion in according more weight to the opinions of Drs. Roberson, Katz, and Soriano than to Roig's attending physicians. Contrary to Roig's argument, it is not a per se abuse of discretion if the administrator does not accord special weight to the opinion of the Roig's treating physician. See Black Decker Disability Plan v. Nord, 538 U.S. 822, 831 (2003). Nor is it a per se abuse of discretion for MetLife to accord greater weight to the opinions of the independent reviewers than to Roig's attending physicians, even though MetLife selected the independent reviewers. See Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (holding that administrator's denial of benefits was not arbitrary and capricious when its "decision simply came down to a permissible choice between the position of the [administrator's] independent medical consultant and the position of the [claimant's] physicians") (cited with approval in Sweatman, 39 F.3d at 602). Nor may this Court impose on MetLife "a discrete burden of explanation" as to why it may have accorded less weight to Roig's attending physicians' opinions. See Black Decker, 538 U.S. at 831. Here, the underlying findings of the independent reviewers are based on Roig's entire record, plus Roig's statements of pain and, in Dr. Katz's case, additional examination and x-rays. Accordingly, the Court finds that MetLife's reliance on the independent reviewers' credible opinions was not an abuse of discretion.
Roig also appears to argue that MetLife abused its discretion by relying on Dr. Katz's IME because Dr. Katz is an orthopedic surgeon, not a neurosurgeon. Roig provides no authority that suggests that an orthopedic surgeon is not qualified to evaluate conditions of the lumbar and cervical spine. Further, Roig points to no provision in the Plan that requires MetLife to consult physicians of the same specialty as Roig's own attending physician. Cf. Meditrust Financial Services Corp. v. Sterling Chemicals, Inc., 168 F.3d 211, 215 (5th Cir. 1999) (declining to find an abuse of discretion in part where plaintiff asserted that the Plan relied on insufficiently trained physicians because plaintiff did not point to any authority requiring the Plan to provide medical specialists when reviewing a claim). Thus, reliance on Dr. Katz's IME and conclusions was not an abuse of discretion. In any event, the other two physicians MetLife consulted did share the same board certification and specialty as Roig's treating physicians.
Based on the evidence before it, the Court finds that MetLife did not abuse its discretion finding the facts underlying the denial of long-term disability benefits on appeal.
2. Review: Policy Interpretation
In Firestone Tire Rubber Co. v. Bruch, the Supreme Court delineated the appropriate standard of review of an administrator's second determination — its interpretation of the terms of the plan and whether the claim falls within those terms. 489 U.S. 101 (1989). The Supreme Court held that "a denial of benefits challenged under § 1132 (a) (1) (B) is to be reviewed under a de novo standard unless the benefit plan gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Id. at 115; see also Schadler, 147 F.3d at 394. When a plan vests discretionary authority in the administrator, "courts review the decision under the more deferential abuse of discretion standard." Schadler, 147 F.3d at 394. Even under this deferential abuse of discretion standard, courts are not "`confined to the administrative record in determining whether . . . [the] plan administrator abused his discretion in making a benefit determination.'" Id. (citing Wildbur, 974 F.2d at 639). The Fifth Circuit has noted that although it "has no desire to wade into the largely semantic" conflict that surrounds an exact definition of the abuse of discretion standard, "if a decision is supported by substantial evidence and is not erroneous as a matter of law, it is not arbitrary and capricious" or an abuse of discretion. Wildbur, 974 F.2d at 637 n. 12.
The Court must therefore determine whether MetLife's policy interpretation is a legally correct interpretation. See id. MetLife is a claims administrator with discretionary authority to interpret the Plan. See Roig I, 2000 WL, at *10. The Court will accordingly review MetLife's ultimate determination for abuse of discretion as required by Schadler.
As noted above, the policy provides that the company will pay benefits to participants who become "Totally Disabled." Adm. Record at LTD-445. After the initial twelve months of disability, "Totally Disabled" means that the participant is under the care of a physician, and cannot work at any occupation for which the participant is reasonably qualified, or could become qualified, by training, education, and experience. Id. at LTD-443. Benefits are not available to participants who can work at some gainful employment after twelve months.
The parties do not dispute MetLife's interpretation of the terms of the Plan. The Court finds that MetLife's interpretation of the Plan and application of the Plan's terms to Roig's claim was not an abuse of discretion. MetLife denied Roig's claim because it found that she was not unable to work at any occupation for which she was or could become reasonably qualified as of July 1999 and beyond. MetLife found that Roig was capable of sedentary to light work, and it used a Transferable Skills Analysis and a Labor Market Survey to determine that jobs existed in Roig's local area which she was capable and qualified to perform. MetLife reasonably concluded that Roig was not disabled from any occupation for which she was reasonably qualified or could become qualified. Thus, MetLife did not abuse its discretion in interpreting and applying the Plan's terms to Roig's claim.
3. Attorney's Fees and Costs
Roig also requests attorney's fees and costs based on MetLife's arbitrary and capricious denial of her claim. ERISA allows a court to award reasonable attorney's fees to the prevailing party in an ERISA action. See 29 U.S.C. § 1332(g) (1); Boggs v. Boggs, 82 F.3d 90, 94 n. 1 (5th Cir. 1996), rev'd on other grounds, 520 U.S. 833 (1997). Because the Court grants summary judgment in favor of Defendant, the Court does not award attorney's fees or costs to Roig.
III. CONCLUSION
For the foregoing reasons, the Court GRANTS the Plan's motion for summary judgment and DENIES Roig's cross-motion for summary judgment.