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MetLife Disability Denial Upheld when Claimant Files Lawsuit Without ERISA Appeal

Attorney Gregory DellAuthor: Attorney Gregory Dell

In Zuke v. American Airlines, Inc., plaintiff had received 13 years of long term disability benefits when MetLife, the plan administrator, terminated them. When Zuke’s administrative appeal was denied, she filed an ERISA lawsuit. When the Ohio district court agreed with MetLife, she appealed. On appeal, the Sixth Circuit held that MetLife’s termination of benefits was arbitrary and capricious since it was based on reviewing doctors’ opinions while ignoring objective evidence of disability included in reports of treating physicians. The case was remanded to MetLife with instructions to conduct a “full and fair inquiry… in accordance with this Court’s precedent.”

Background

Mar-Ya Zuke was employed by American Airlines as a sales and service representative when she was severely injured in a car accident. She was disabled and received long term disability benefits for 13 years when MetLife sent her a letter requesting medical information to support her claim for continuing benefits. She said she sent what was requested, but there was some confusion about whether MetLife received all the documents that were faxed to it. Ultimately, her benefits were terminated.

Zeke followed the steps for an administrative appeal and provided documentation to support her claim. MetLife had independent medical specialists review her medical records. All reviewers concluded there was no objective evidence of her disability. MetLife again terminated her benefits and she filed an ERISA lawsuit in an Ohio district court. That court agreed with MetLIfe and Zuke filed an appeal.

On appeal, the Sixth Circuit analyzed the medical records and decided MetLife acted arbitrarily and capriciously and had denied Zeke a “full and fair review” when it engaged in a “selective review of the administrative record” in order to support its decision to deny coverage.

MetLife Erroneously Terminated Benefits Based on its Selective Review of the Administrative Record

After review of the medical records, the Sixth Circuit found that “the Plan’s conclusion that there was no objective evidence contradicts the record.” The record included:

  • Zuke’s spinal MRIs showed “fairly extensive degenerative disease” and a “new disc herniation.”
  • The results of a Spurling test indicated she suffered from radicular pain.
  • A physician’s noted she had a limited range of motion of the right shoulder.

The court noted that, “a treating physician’s notes detailing functional capabilities of a patient are objective evidence.” Although plan administrators are not required to “accord special deference to the opinions of treating physicians,” when they dismiss objective findings from treating physicians, “it suggests that the Plan’s decision was not a result of a deliberate, principled reasoning process.” In this case, the court concluded that the plan did not provide Zuke with a full and fair hearing.

The Remedy

Since the error was with “the integrity of the plan’s decision making process, rather than a claimant was denied benefits to which [she] was clearly entitled,” the case was remanded to the plan administrator with instructions to conduct a full and fair review of Zuke’s claim.

This case was not handled by our office, but we believe it can be instructive for those who have been receiving long term disability benefits for a number of years and are faced with the need to provide their plan administrators with documentation of the continuing disability. If you have about your disability benefits, contact one of our attorneys for a free consultation.



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