• Lawyer Tips for a MetLife Disability Denial, Appeal & Lawsuit

Judge Agrees that MetLife’s Denial of Long Term Disability Benefits was Reasonable

In Anne Ehlert v. Metropolitan Life Insurance Company (MetLife), Ehlert was a consulting pension actuary for pension plans at Towers Watson. Her first day of work with Towers was September 8, 2003. Her last day of work was December 23, 2015. In August 2016, she applied for long-term disability (LTD) benefits under her employer’s disability insurance benefit plan which was administered by MetLife.

In this case, in order to collect LTD benefits, Ehlert had to prove that due to an illness or accidental injury, she was unable to perform the duties of her own occupation. She claimed she was unable to perform these duties due to “fatigue, short term memory and cognitive organizational issues, [and] headaches.” Her claim was denied, so she appealed. When her administrative appeal was denied, she filed this ERISA lawsuit in the United States District Court for the District of Massachusetts.

The District Court analyzed four issues raised by Ehlert: 1) She was denied a full and fair review; 2) MetLife rejected evidence presented by her functional capacity evaluation (FCE); 3) MetLife rejected the report of a vocational consultant; and 4) MetLife did not give proper consideration of the award of Social Security Disability Income (SSDI) benefits awarded to her by the Social Security Administration (SSA).

The Court made a comprehensive review of Ehlert’s medical records and reports of treating physicians as well as MetLife’s reviewing physicians. Ultimately, the Court concluded that Ehlert had not sustained her burden of proving she was unable to perform the material duties of her own occupation. Therefore, MetLife did not abuse its discretion when it denied her claim for LTD benefits.

The Court stated: “MetLife made a carefully-considered decision to deny Ehlert’s application and appeal for LTD benefits. That decision was reasonable and supported by substantial evidence in the record. Under the arbitrary and capricious standard, the decision to deny LTD benefits must be upheld.”

MetLife Provided Ehlert a Full and Fair Review

The terms of MetLife’s disability benefit policy at issue in this case was whether Ehlert was entitled to LTD benefits because she was unable to perform the material duties of her own occupation. As the Court stated, “The issue is whether Ehlert submitted proof that she suffered such physical or cognitive limitations that she was disabled from working within the meaning of the LTD plan.”

There was no selective review of treating physicians. The Court noted, “There is no dispute that Ehlert has a lengthy history of reported, consistent symptoms. MetLife and its consultant physicians did not merely gloss over the treating physicians’ notes and opinions. Rather, her treating physicians’ longitudinal reports concerning these physical and cognitive limitations were recognized and acknowledged.”

Although the law is clear that a “plan administrator may not ‘cherry-pick the evidence it prefers while ignoring significant evidence to the contrary,’” the Court was clear that is not what happened here. Some of Ehlert’s numerous treating physicians opined she could not work. Others acknowledged she suffered from pain and cognitive issues but believed she could still work at her regular job. The Court meticulously analyzed all reports from Ehlert’s treating physicians.

In addition to Ehlert’s reports to her physicians of pain and cognitive limitations, she also reported that she went biking and swimming. She walked her dog, hiked, and went to the gym. One treating physician repeatedly stated that she could sit for 6-8 hours a day so could do her sedentary job. Another treating physician noted that she could work from home four hours a day.

The Court analyzed reports of MetLife’s reviewing physicians, all of whom opined that she could perform the duties of her regular occupation. The physicians had reached out to Ehlert’s physicians and, “where possible, had teleconferences to discuss Ehlert’s case. Lengthy and comprehensive consultant physician reports were submitted. Ehlert’s LTD benefits decision was thirteen pages in length and detailed.”

The Court made it clear that just because the “physician consultants disagreed with plaintiff’s treating physicians does not mean that they ‘deemphasized’ their clinical evaluations and findings.”

MetLife did not reject the FCE. A physical therapist performed an FCE, a four-hour test in this case. The therapist opined that Ehlert could not work at a sedentary or light physical capacity on a full-time basis and concluded that Ehlert’s fatigue and other symptoms were “due to Lyme Disease.”

MetLife’s reviewing consultant disagreed with the opinion, stating the physical therapist “was not a physician and [was] not qualified to offer such an opinion.” There were other tests administered to Ehlert that contradicted the conclusions presented by the physical therapist in the FCE. Plus, the Court found that during this same time period, Ehlert reported she was riding her bike seven miles three or four times a week and frequently swimming, even at the same time she was saying she could not work because of fatigue.

The Court concluded, “In sum, the FCE is not the only evidence bearing on Ehlert’s functional limitations.” The Court held it was not its place to determine the weight MetLife should have given to the FCE.

MetLife did not reject the report of the vocational consultant. A vocational consultant reviewed the medical records as well as Ehlert’s education and vocational history. The consultant concluded that Ehlert could not manage “even Sedentary, part time work.” The consultant criticized the reports of MetLife’s consulting physicians since none of them had personally examined Ehlert.

The opinion of the consultant is contrary to the law of this circuit where courts “have treated a nonexamining physician’s review of a claimant’s file as reliable medical evidence on several occasions.”

Consideration of SSDI benefits. The decision of the SSA to award SSDI benefits is not binding on disability insurance companies. The criteria relied on by the SSA is different than what MetLife relies on. According to the Court, “it was up to MetLife to determine the weight to be afforded the decision awarding SSDI benefits.”

This case was not handled by our office, but we believe it can be helpful to claimants who are struggling to meet their burden of proof so they will qualify for LTD benefits. If you have questions about this case, or any aspect of your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

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