MetLife Denies Third Claim for Disability Benefits After Approving Two Separate Prior Claims for Disability Benefits for Chronic Fatigue Syndrome Sufferer

In Bosley v. Metropolitan Life Insurance Company (MetLife), plaintiff Robert Bosley, a registered nurse, has his 2009 claim for long term disability approved by MetLife. He received benefits from 2008 until 2010 at which time he returned to work in sedentary “desk job” position. In 2011, he again received long term disability benefits running from 2011 until 2012 when he returned to work as an advice nurse at a call center.

In 2014, Bosley submitted a third claim for long term disability benefits again based on his suffering from chronic fatigue syndrome. His third claim was denied on the grounds that his medical record did not support his claim for disability “within the meaning of the plan.” His subsequent appeal was denied. After he exhausted his administrative remedies, he filed this ERISA lawsuit.

Bosley filed a Motion for Summary Judgment in the U.S. District Court for the Northern District of California. He asserted that since MetLife “paid the prior claims on essentially the same basis as that asserted in his 2014 claim” it erred in denying his third claim for benefits.

The Court found that Bosely was “wrong, however, in representing that MetLife previously approved his long-term disability claim based on the same medical record as in the 2014 claim. The claim files from 2009, from 2011 and 2014 reveal a much more complicated medical history, shedding light on MetLife’s decision calculus in those claims casting doubt on the sufficiency of Bosley’s 2014 claim.”

The court denied the summary judgment motion and ordered the case to be heard at a bench trial. The court noted there were several genuine issues of material fact that precluding the court from granting the summary judgment “on the question of whether Bosley was in fact disabled within the meaning of the plan in 2014.”

Examples of Issues of Material Fact Precluding Summary Judgment

The Court found a number of issues of material fact that could not be decided based on the evidence before it.

· There were significant differences in the 2009, 2011 and 2014 claims. Bosley’s previous claims for disability were not based entirely on his chronic fatigue syndrome. For the disability period of 2008 to 2010, he also suffered from numerous other medical problems such as hypertension, depression, skin lesions, back pain, vision problems and other. During the disability period of 2011 to 2012, he was hospitalized for a period of time and underwent two separate surgeries “in connection with a gastrointestinal tumor and postoperative complications.

· Two of Bosley’s treating physicians expressed skepticism as to the extent of his disability in his 2014 claim. For the 2014 claim, one treating physician reported that Bosley was not “trying” and needed to “exert himself and exercise more. Another treating physician ordered Bosley to work with mental health services and undergo motivational interviewing in order for her to give him any more “work excuse letters.”

The Court stressed that this is not an exhaustive list of factual issues in dispute precluding its grant of the summary judgment motion.

Bench Trial Instead of Remand to MetLife is the Proper Remedy

Although ERISA cases are generally “tried on the administrative record,” the Court noted that it did have discretion to admit additional evidence when necessary for an adequate review. The Court expected to hear sworn testimony from both sides, including from Bosley and the “reasoning of medical professionals on both sides.” Additionally, the Court contemplated appointing an independent medical expert to help evaluate the medical evidence and determine “to what extent Bosley’s chronic fatigue syndrome impaired his ability to function.”

This case was not handled by our office, but if you need assistance on a similar matter, please to contact us for a free consultation.

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