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Mowery v. Metropolitan Life Insurance Co.

United States District Court, W.D. Wisconsin

June 2, 2017

LISA MOWERY, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY and DIGNITY HEALTH'S HEALTH AND WELFARE PLAN, Defendants.

          OPINION & ORDER

          JAMES D. PETERSON District Judge.

         Plaintiff Lisa Mowery worked as the lead registered nurse in French Hospital's Intensive Care Unit and Critical Care Unit until she had a series of allergic reactions, leading to several emergency room visits. Since then, Mowery has stopped working, sought treatment from a number of doctors, and started a daily regimen of numerous antihistimines and other medications. Despite her efforts, she still suffers allergic reactions. Mowery and her doctors are not sure exactly what causes these reactions, although tests indicate that she is allergic to at least two chemicals found in a number of common products.

         Mowery submitted a claim for long-term disability benefits under defendant Dignity Health's Health and Welfare Plan, administered by defendant Metropolitan Life Insurance Company. Defendants denied Mowery's claim. Mowery filed this suit, claiming that their decision violated her rights under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment. Dkt. 13 and Dkt. 17. The denial of benefits was based almost exclusively on the opinion of MetLife's independent physician consultant, Dr. Lin. But Dr. Lin's reports contained fundamental errors and disregarded some of the evidence provided by Mowery's treating physicians. The court concludes that defendants arbitrarily and capriciously denied Mowery benefits. The court will grant Mowery's motion, deny defendants' motion, and remand for further administrative proceedings consistent with this opinion.

         UNDISPUTED FACTS

         The following facts are undisputed unless otherwise noted.

         Mowery is a registered nurse. She worked for Dignity Health as the lead registered nurse in French Hospital's Intensive Care Unit and Critical Care Unit. As a Dignity Health employee, Mowery was eligible for coverage under Dignity Health's Health and Welfare Plan. The plan is covered by ERISA. MetLife is the claims administrator for the plan. Dignity Health and MetLife both have discretionary authority to administer the plan.

         On March 4, 2013, Mowery had an allergic reaction while working in the Intensive Care Unit and went to the emergency room for treatment. Mowery already knew that she was allergic to bee venom, latex, and several kinds of antibiotics, but neither she nor her doctors knew what caused the March 4 reaction, so she began working in the education area of the hospital until she could determine the cause. While working in the education area on March 26, she had another allergic reaction and went to the emergency room for treatment. Mowery did not return to work until after she met with an allergist, Dr. Helen Mawhinney, who told Mowery that she could return to work.

         On Mowery's first day back at work, April 26, she had another allergic reaction. She took medications to control her symptoms, finished her shift, and returned home. But in the middle of the night, she woke up with more severe symptoms and went to the emergency room. At that point, Mowery decided not to return to work. On December 3, she applied by phone for long-term disability benefits under the plan, claiming that “allergies to gloves and paper and glue” prevent her from working. Dkt. 12-15, at 15.

         A. The plan's definition of disability

         To receive long-term disability benefits, Mowery had to provide evidence that she was disabled as defined by the plan, that is, that “as a result of Sickness or injury, ” she was “unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue Your Usual Occupation in the usual and customary way.” Dkt. 12, at 27.

         The plan defines “Substantial and Material Acts” as “the important tasks, functions and operations generally required by employers from those engaged in Your Usual Occupation that cannot be reasonably omitted or modified.” Id. at 28. The plan defines “Usual Occupation” as “any employment, business, trade or profession and the Substantial and Material Acts of the occupation You were regularly performing for the employer when the Disability began. Usual Occupation is not necessarily limited to the specific job that You performed for the employer.” Id.

         B. Mowery's claim record

         Over the next year and a half, Mowery provided medical records and other documents to support her claim. By the time MetLife made its final determination about Mowery's eligibility for long-term disability benefits, it had the following documents before it.

         a. March 4, 2013 emergency room records

         Records from Mowery's March 4 visit to the emergency room indicate that she had an “acute anaphylactic reaction, ” including the following symptoms: “a diffuse, pruritic, red, raised rash along her entire body and her face, tongue swelling, ” as well as “5/10 chest pressure, anxiety, . . . . borderline hypoxic . . . . [d]iffuse urticarial hives throughout face, chest, back and extremities.” Dkt. 12-14, at 5-6. Mowery was immediately administered epinephrine, Benadryl, Zantac, and other allergy medicines and monitored in the ER for four hours.

         b. March 26, 2013 emergency room records

         Records from Mowery's March 26 visit to the emergency room indicate that she had a “[r]ash consistent with allergic reaction, ” and describe her symptoms as “circumferential erythema to the bilateral hands up to the wrists [and] non-raised erythema and some welts on her back, some hives on her back [and] erythema that is just, again, flat, non-raised in the nape of her neck.” Dkt. 12-14, at 8. She was administered antihistamines and observed for 45 minutes, at which point her symptoms had resolved.

         c. Dr. Mawhinney's April 2, 2013 report

         Mowery saw Dr. Mawhinney, an allergist, on April 2 to determine the cause of her recent allergic reactions. Dr. Mawhinney performed a blood test “to a panel of environmental allergens.” Dkt. 12-13, at 83. “Somewhat surprisingly, given the patient's history, there were no positive reactions.” Id. Dr. Mawhinney noted that because “there is no obvious explanation for the patient's episodes of anaphylaxis, I believe that she requires maximum protection from symptoms.” Id. Mawhinney stated that Mowery could “return back to work on 04/26/2013.” Dkt. 12-10, at 23.

         d. April 27, 2013 emergency room records

         Records from Mowery's early-morning visit to the emergency room on April 27 indicate that she had “hoarse voice, itching, redness of skin, [and a]bdominal cramps.” Dkt. 12-14, at 9. The records list a differential diagnosis of “anaphylaxis, Mastocystosis urticaria” and note that an allergic reaction is “suspected.” Id. at 9, 10. They indicate that Mowery had taken Benadryl and epinephrine before arriving at the hospital. A blood test for tryptase (a serum associated with anaphylactic reactions) was performed shortly after Mowery arrived. The results indicated that Mowery's tryptase levels were within the normal range.[1] Dkt. 12-14, at 21. Mowery was discharged from the hospital about an hour and a half after she arrived with instructions to avoid her “work environment” until she could be evaluated further. Id. at 11.

         e. June 7, 2013 emergency room records

         Mowery visited the emergency room again on June 7, 2013, after taking Benadryl and epinephrine at home. The records note “flushing” on Mowery's arms and chest. Dkt. 12-14, at 14. They indicate that Mowery's symptoms gradually resolved and that she asked to be discharged about an hour and a half after she arrived. The treatment provider agreed that discharge was appropriate because “her exam is completely normal and not worrisome for anaphylaxis or angioedema.” Id. at 14-15.

         f. Dr. White's January 31, 2014 Attending Physician Statement

         Mowery's primary care physician, Dr. Klyda White, completed an Attending Physician Statement (APS) form supplied by MetLife on January 31, 2014, in which she describes Mowery's condition as “fixed and stationary.” Dkt. 12-14, at 31. In response to the question “Have you advised your patient about when they can return to work?” Dr. White stated “Yes” and listed “Permanent” as the date of return. Id. (Later, Dr. White explained that she was confused by the question and meant to indicate that Mowery's “inability to return to work was permanent.” Dkt. 12-10, at 8.)

         g. Dr. McLean's August 5, 2013 report

         Mowery underwent several patch tests to identify contact allergens and met with Dr. Arthur McLean on August 5 to discuss the results. In his report, Dr. McLean notes that the tests revealed positive results for p-tert butyl phenol formaldehyde resin (PTBP-FR)[2] and methyldibromo glutaronitrile (MDBGN).[3] In addition, Mowery exhibited “strong reactions” to the glue applied to keep the patch test attached to the skin. Dkt. 12-13, at 93. Although Dr. McLean's report does not mention this, the lab report for one of the patch tests indicates that Mowery exhibited “macular erythema” (a rash) in response to mercaptobenzothiazole (MBT).[4]Dkt. 12-13, at 21. A patch test was also performed with “small pieces of the Nitrile gloves.” Dkt. 12-13, at 93. The results were negative.

         Dr. McLean noted that Mowery's “more serious” anaphylactic episodes “seem to occur more commonly in environments where Nitrile gloves have been utilized. As noted the tests to small pieces of Nitrile gloves was negative but the [patch] test was positive to [MDBGN, ] which could represent a degraded antigen resulting from chronic use of Nitrile gloves.” Dkt. 12-13, at 26-27. Dr. McLean instructed Mowery to “avoid areas where nitrile gloves have been used due to [her MDBGN] sensitivity.” Id. at 27.

         h. The August 12, 2013 denial of Mowery's ...


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