The United States District Court for the Southern District of New York recently held that MetLife’s decision to deny benefits to a Plaintiff was unreasonable and ordered MetLife to reconsider Plaintiff’s Long Term Disability claim.
Plaintiff was 39 years old when MetLife approved his short-term disability claim due to herniated discs in his cervical and lumbar spine, scoliosis, canal stenosis, carpal tunnel syndrome, cervical radiculopathy and other medical conditions.
Plaintiff flew to Cairo, Egypt one month after being approved for Disability benefits
Approximately one month after being approved for short-term benefits, Plaintiff flew to Cairo, Egypt where his parents live. Two weeks earlier Plaintiff contacted MetLife of his plans to travel and MetLife in turn, launched an internal investigation of Plaintiff’s claim believing that his flying to Egypt was inconsistent with Plaintiff’s claim of disability.
MetLife terminates Plaintiff’s benefits after a year and nine months of approving Plaintiff’s disability claims
After paying Plaintiff benefits for the maximum period allowed under the short-term disability plan, MetLife approved Plaintiff’s claim for LTD benefits. However, in January 2009, MetLife decided to close Plaintiff’s claim after a year and nine months of approving his disability claims even though there had not been any significant change in Plaintiff’s condition.
Plaintiff submitted an ERISA Appeal and MetLife upheld the termination of benefits. As a result, Plaintiff and his New York disability attorney filed an ERISA lawsuit seeking judicial review of MetLife’s final decision.
Court concludes that MetLife’s determination was unreasonable
After reviewing the administrative record the U.S. District Court for the Southern District of New York found that MetLife’s denial of benefits was wrong. Accordingly, judgment was entered in favor of the Plaintiff.
In reaching its decision, the court explained that MetLife improperly relied on Independent Medical Reviews conducted by physicians retained by MetLife. The court pointed out that two of MetLife’s physicians did not have an opportunity to physically examine Plaintiff and their opinions were based solely on the medical records. Furthermore, one of MetLife’s doctors ignored Plaintiff’s subjective complaints of pain and had disqualified diagnostic tests because they were illegible.
The court also refused to accept one MetLife doctor’s conclusion that the Plaintiff’s ability to endure a flight to Egypt was inconsistent with his claims of disability explaining that Plaintiff’s pre-disability occupation; which required sitting, programming and typing for up to eight hours a day, five days a week was distinct from flying. Furthermore, the court explained that many people are able to travel internationally while on sedatives or other medication that would otherwise impair their job performance.
In sharp contrast to MetLife’s findings, Plaintiff had submitted substantial evidence of his conditions from six different examiners – all of which were unanimous about Plaintiff’s diagnoses – and two functional capacity evaluations. MetLife did not conduct its own functional capacity evaluation and did not request a description of Plaintiff’s job duties until four months after its initial denial of Plaintiff’s claim. The absence of a job description prior to the initial denial raised questions about whether Plaintiff’s claim was fairly and adequately reviewed.
Considering all the evidence, the Court found MetLife’s determination was unreasonable and ordered MetLife to reconsider Plaintiff’s claim in light of the Court’s findings and all the evidence submitted.