Federal judge reverses MetLife’s denial of long-term disability benefits to a senior project manager suffering from back pain

Mrs. Kaufmann was employed as a senior project manager by Siemens Corporation.  Mrs. Kaufmann was a member of the long term disability plan through MetLife,  who was both the administrator and payor of disability benefits.  On May 26, 2006, Mrs. Kaufmann stopped working on advice from her treating physician, Dr. Daniel T. Rubino.  Because of an unsuccessful diskectomy and laminectomy, Mrs. Kaufman suffered from severe chronic pain. Mrs. Kaufman suffered from progressive back pain, disc protrusion and herniation, stenosis and radiculopathy which led her to seek help from those unsuccessful surgeries.

MetLife initially paid disability benefits, but then terminated them on November 9, 2007, claiming that Mrs. Kaufmann had failed to provide evidence that she was unable to perform the duties of her occupation.

Mrs. Kaufmann claimed that the basis for the denial was that Met Life mischaracterized her ‘light duty job’ as a ‘sedentary’ job.  On February 4, 2008, Dr. Rubino completed a narrative report stating that his patient “cannot sit or stand for longer than 15 minutes without changing positions due to chronic pain impulses.  She has severely decreased concentration ability, preventing her from having gainful employment, not to mention her physical limitations.” He also added that “as of August 21, 2007, Nancy was no longer able to perform her pre-injury job with Siemens Corporation on a full-time sustained basis.”

Prior to her care with Dr. Rubino, Mrs. Kaufmann had multiple diagnostic tests and exams which confirmed her spinal pain.  Her orthopedic surgeon, Dr. Richard Balderston, stated that surgery would most likely make her situation worse and that the best treatment she could receive would be pain management.  The same opinion was had by Dr. Howard Richter, a neurosurgeon who also commented on her “chronic and worsening left leg pain of uncertain origin.”

Met Life referred the case to Dr. Frank Nisenfeld, who reviewed only records with no examination of Mrs. Kaufmann.  After a review of Mrs. Kaufman’s medical records, Dr. Nisenfeld concluded that the treating physicians were correct and that the condition would not improve, including his statements that there were ‘no surgical or medical answers.’  He concluded that medications would most likely cause functional impairment as well as safety risks.  Still, because of Met Life’s classification of Kaufmann’s job as sedentary, he opined that Mrs. Kaufman’s medical problems should not prevent her from performing sedentary work.

When Metlife terminated disability benefits in November of 2007, the letter stated, Based on the findings of the review, there was no medical documentation to support an ongoing functional impairment that would limit your ability to perform your sedentary occupation.”

After this denial, Dr. Rubino sent Mrs. Kaufmann to Dr. Wendy Wang, who did a comprehensive and thorough functional capacity evaluation on December 12, 2007.  Dr. Wang took into account each of Kaufmann’s job duties and whether or not they would be affected by her illnesses. She concluded that as a product manager, Mrs. Kaufmann was required to travel by plane or car at least once a week, with a suitcase weighing more than 30 lbs.,  that she must be able to perform prolonged walking, sitting, driving, pulling, lifting and more.  Dr. Wang concluded that Mrs. Kaufmann was unable to perform these duties, or to live up to the mental component required by the job.

The case was then referred by Met Life to Dr. Ephraim Brenman, who conducted a review and found that Kaufman was “not precluded from working full time in any capacity,” and “is able to work full time, at least a sedentary level of duty.”  Kaufmann’s doctor, Dr. Rubino, commented on Dr. Brenman’s findings, stating that there were subjective complaints, documented by objective findings in the medical reports and that “even if there were none [objective findings], this does not preclude her from having these problems.”

On April of 2008, Met Life informed Mrs. Kaufmann that they were upholding their decision to terminate disability benefits based on the report from Dr. Brenman.  Several things must be considered here.  Although Dr. Nisenfeld agreed with Dr. Rubino on certain points, he said that Kaufmann should be able to perform her job.  However, Dr. Nisenfeld was never given a job description of Kaufmann’s occupational duties, and never examined her personally.  Met Life’s experts never looked thoroughly at Dr. Wang’s report and never offered anything up to suggest that Dr. Wang’s report was wrong or that the details could be interpreted differently. Dr. Brenman never even considered or commented on the situation at hand, he only gave a vague analysis to the situation without knowing what Kaufmann’s work duties were.

Kaufman filed a lawsuit in federal court and the court found in favor of Kaufmann on the basis that Met Life’s decision to deny benefits was not supported by substantial evidence and in fact, it was arbitrary and capricious.

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