Citations
- 245 F. Supp. 2d 207
Full opinion text
MEMORANDUM OF DECISION
KRAVCHUK, United States Magistrate Judge.
Plaintiff Vicki Sidou, M.D., has filed suit seeking, among other things, judicial review of various determinations made by the Defendants in connection with Dr. Si-dou’s requests for disability benefits. One of the principal defendants, The Paul Revere Life Insurance Company (“Paul Revere”), has moved to dismiss the principal claim against it on the ground that Dr. Sidou failed to exhaust internal administrative remedies prior to filing suit. Paul Revere has also moved to dismiss the remaining claims against it based on the doctrine of ERISA preemption. In opposition, Dr. Sidou argues that her claim for benefits should be deemed denied, and therefore ripe for review, because of unreasonable and excessive delay on Paul Revere’s part, including delay beyond the administrator’s self-imposed deadlines. By way of her own, affirmative motion, Dr. Sidou also asks the Court to rule at this juncture that Paul Revere’s deemed denial is subject to de novo review. I now deny Paul Revere’s Motion to Dismiss with respect to Counts I and II and deny Paul Revere’s Motion for Remand. I also now grant Dr. Sidou’s Motion for Determination of Standard and Scope of Review, with the qualification that Paul Revere’s determination will be reviewed under the so-called “arbitrary and capricious” standard.
Procedural Posture
Paul Revere captions its motion as a “Motion to Dismiss.” Pursuant to Rule 12(b), there are seven categories of defenses that may be first raised by motion, including a motion to dismiss for failure to state a claim. Normally, when a court considers a Rule 12(b) motion to dismiss, it does so based solely on the pleadings. Rule 12(b) provides an exception, however, for motions “asserting the defense numbered (6) to dismiss for failure of the pleading to state a claim upon which relief can be granted.” When 12(b)(6) motions are presented, the court can consider “matters outside the pleadings.” Fed. R.Civ.P. 12(b). Neither party has addressed whether Paul Revere’s “failure to exhaust” argument amounts to a 12(b)(6) motion as opposed to, for example, a subject matter jurisdiction challenge. Furthermore, Paul Revere’s motion, if treated as a 12(b)(6) motion, is tardy. Paul Revere has already filed its Answer to Dr. Sidou’s Amended Complaint and Rule 12(b) motions “shall be made before pleading.” Id.
In any event, Dr. Sidou has not objected to Paul Revere’s motion on this ground and her own filings are filled with numerous record citations that go beyond the material allegations of the Amended Complaint. For this reason, I construe Paul Revere’s motion as a motion for judgment on the pleadings, pursuant to Rule 12(c), which permits me to consider matters beyond the pleadings in a motion filed after the defendant’s answer.
Facts
Because I treat Paul Revere’s Motion as a motion for judgment on the pleadings, but gather the facts from more than just the pleadings, it is appropriate to construe those facts pursuant to the summary judgment standard, see Fed.R.Civ.P. 12(c), which means that I will interpret them in the light most favorable to Dr. Sidou in circumstances where the materials are reasonably subject to more than one interpretation. Fireman’s Ins. Co. v. Todesca Equip. Co., 310 F.3d 32, 34 (1st Cir.2002).
The parties are in agreement that the Plaintiff, Dr. Sidou, is entitled to receive long term disability benefits, under a certain Paul Revere Group Policy, for a disabling health condition she has suffered with since June 1996. The central dispute between Dr. Sidou and Paul Revere concerns whether Dr. Sidou’s disability is caused by or contributed to by a mental disorder. If it is, then her benefits expired sometime in late 1998 or early 1999. The pending motions do not call upon the Court to resolve that issue at this time. Instead, the pending motions address only whether Dr. Sidou exhausted her administrative remedies and, if so, what standard of review the Court should apply when it comes time to review Paul Revere’s determination of her claim and subsequent appeal. The following facts are material to these questions.
In June 1996, while employed as an anesthesiologist by Northeast Anesthesia Professional Association (“Northeast”), Dr. Sidou developed a condition that caused her treating physician to conclude that Dr. Sidou could not continue to perform her duties on a full time basis. Dr. Sidou and Northeast reduced her work schedule accordingly. At the time, Dr. Sidou was an eligible participant in a certain Northeast employee disability benefit plan identified as Paul Revere Group Policy No. G-86014, a group insurance policy both issued and administered by Paul Revere. As an eligible plan participant, Dr. Sidou was entitled to partial disability benefits if she could not perform all of the important duties of her occupation on a full time basis and was earning less than 80% of her prior earnings. Dr. Sidou applied to Paul Revere for disability benefits in December 1996, following the reduction in her work schedule at Northeast. Paul Revere denied Dr. Sidou’s claim for disability benefits by letter dated June 13, 1997 on the ground that there was insufficient evidence of a disability.
Meanwhile, in September 1996, Dr. Si-dou’s employer changed from Northeast Anesthesia Professional Association to Spectrum Medical Group, Northeast Anesthesia Division (“Spectrum”). On August 27, 1997, Dr. Sidou filed an appeal of Paul Revere’s denial of her claim for disability benefits under the Paul Revere Group Policy. Roughly two months later, in a letter dated October 6, 1997, Paul Revere responded that it had reviewed her appeal and found “no medical evidence and no basis for any limitations” in Dr. Sidou’s ability to perform her occupation. (1-317.) Based on this assertion, Paul Revere denied Dr. Sidou’s appeal. A one-sentence paragraph in the letter informed Dr. Si-dou, “This is our final determination with regards to this claim.” (Id.)
Subsequently, in or about October 1998, Dr. Sidou’s symptoms became more severe. On or about October 6, 1998, Spectrum placed Dr. Sidou on medical leave. In December 1998, Stephanie R. Lash, M.D., diagnosed Dr. Sidou’s condition as neurally mediated syncope, a type of primary autonomic dysfunction that is classified as an “organic disease.” (4-39; 6-106.) In light of this diagnosis, Dr. Sidou again asked Paul Revere to reconsider her earlier claim for disability benefits. In early 1999, Dr. Sidou submitted a claim on a form bearing the designation of New England Financial, which Paul Revere characterizes as a claim made both to it and to New England Financial. Dr. Sidou intended with her 1999 claim to recover benefits not only for present and future lost wages, in light of the December 1998 diagnosis, but also benefits extending back to her initial, 1996 claim under the Paul Revere Group Policy. On March 9, 1999, counsel for Dr. Sidou faxed a letter to a New England representative in which he stated that Dr. Sidou had been diagnosed by Horacio Kaufmann, M.D., as having “primary autonomic dysfunction, characterized as neurally mediated syncope,” and that “[w]e wish to do whatever is necessary to renew Dr. Sidou’s application for partial disability benefits under the Paul Revere policy.” (4-50, 51.) Enclosed with the letter were copies of both Dr. Lash’s December 1998 report and Dr. Kaufmann’s January 1999 report. According to counsel for Dr. Sidou, “The gist of these reports is that Dr. Sidou’s symptoms since at least the fall of 1996 are attributable to this syndrome.” (4-50.)
In a letter dated March 11, 1999, Janice H. King wrote to Dr. Sidou and acknowledged receipt of the 1999 claim form. Ms. King’s signature line indicated that she was a senior claim representative for New England Financial. It did not indicate that she was an employee or agent of Paul Revere. However, regarding Dr. Sidou’s request that her claim be considered back to 1996 under the Paul Revere Group Policy, Ms. King stated:
We will consider our liability back to that date, but to be of service to you, we will open the claim October 6, 1998 and proceed from there so that any benefits that come due under that part of the claim may be paid promptly. Should we be able to approve the claim back to 1996, appropriate adjustments would be made.
(4^44.) At this time, Ms. King began to gather medical records in order to review the claims, including treatment summaries from Dr. Sidou’s psychologist, Joan Settin, Ph.D. Dr. Settin, in accordance with her practice, refused to release her personal notes taken during the therapy process. Nevertheless, Ms. King, with the aid of a medical consultant and a cardiac consultant, reviewed these materials and others subsequently submitted by Drs. Settin and Wood, and concluded that Dr. Sidou had been disabled as early as September 1996, but that the disability was caused or contributed to by “stress and anxiety” and was therefore subject to an “Other Limitations” provision in the Paul Revere Group Policy. This provision imposes a two-year limit on the payment of benefits where, among other things, a “mental disorder” causes or contributes to the disability at issue. In effect, Paul Revere reversed its prior denial of the claim, but limited benefits to two years. Ms. King informed Dr. Sidou of this determination in a letter dated December 14, 1999. Ms. King’s letter also informed Dr. Sidou that any appeal should be sent within 90 days and that “The Claims Department” would make its final determination within 60 days of receipt of an appeal. This letter clearly indicated that Ms. King was a “Senior Claims Representative” for both “The Paul Revere Life Insurance Company and The New England Disability Claims Unit.” The return address indicated on the letter:
The New England Claim Unit/Paul Revere Group Claims
Quality Performance Support, 700-19
18 Chestnut Street
Worcester, MA 01608
Dr. Sidou, through counsel, appealed this determination in a March 20, 2000 letter. Dr. Sidou’s appeal was supported, in part, by a 26-page “Comprehensive Psychiatric Evaluation” conducted by David J. Bourne, M.D., based on Dr. Si-dou’s past treatment histories and reports and an examination conducted by Dr. Bourne on February 17, 2000. Ms. King responded in a letter dated April 12, 2000 that the appeal had been received and that it would be further reviewed by psychiatric and medical consultants due to the inclusion of Dr. Bourne’s evaluation.
Ms. King referred the file to a psychological consultant, Alex W. Unsprung, Ph. D., who reviewed the entire file and concluded that Dr. Bourne’s evaluation was “compelling.” His conclusions regarding the cause of Dr. Sidou’s disability included the following:
Even if a case can be made that Dr. Sidou’s syncopal episodes are being triggered by psychological factors, ... I would suggest that the problem is still not so much psychological as it is a matter of an abnormal physiological response, and the condition is thus physical, not psychological.... [Dr. Sidou] appears to react in psychologically normal and healthy ways, but may have abnormal physiological responses.
(6-219, 220.) Dr. Ursprung conveyed these conclusions to Ms. King by way of a memorandum dated May, 10, 2000, which was at least ten days prior to the expiration of the 60-day, self-imposed deadline for adjudicating Dr. Sidou’s appeal. However, allegedly harboring concerns that Dr. Ursprung had relied too heavily on Dr. Bourne’s evaluation, and that Dr. Bourne had in turn relied too heavily on Dr. Si-dou’s “self report” and Dr. Settin’s summaries, Ms. King attempted more than three weeks later to refer the file to a second psychological consultant identified only as “Dr. Cusher.” According to a hand-written notation penned by Ms. King on June 7, 2000, Dr. Cusher asked Ms. King to obtain Dr. Settin’s notes before referring the file to him. Recognizing that the 60-day deadline was at hand, Ms. King notified Dr. Sidou in a June 7, 2000 letter that an extension of time was required, stating,