United States District Court, W.D. Wisconsin
OPINION & ORDER
D. PETERSON District Judge.
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
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.
following facts are undisputed unless otherwise noted.
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.
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.
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.
The plan's definition of disability
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.
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.
Mowery's claim record
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.
March 4, 2013 emergency room 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
March 26, 2013 emergency room 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.
Dr. Mawhinney's April 2, 2013 report
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.
April 27, 2013 emergency room 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. 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.
June 7, 2013 emergency room records
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.
Dr. White's January 31, 2014 Attending Physician
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.)
Dr. McLean's August 5, 2013 report
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) and methyldibromo glutaronitrile
(MDBGN). 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).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.
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.
The August 12, 2013 denial of Mowery's ...