Court Rules That MetLife Improperly Limited Proof Of Claim To Only Objective Data

In Roberts v. Metro. Life Ins. Co., C.A. No. 6:18-cv-725-TMC (D. S.C. Sept. 3, 2019), Plaintiff worked for IBM for more than eighteen (18) years when he stopped working in September 2010 due to intractable migraine headaches and cervical pain. He filed claims for Social Security (“SS”) disability benefits and short term disability (STD) benefits with MetLife, which is the claims administrator for the Plan. Roberts was approved for SS disability in August 2012. He was also approved for STD and received benefits for six months.

When the STD benefits were exhausted, Roberts applied for LTD benefits under the Plan. Roberts was approved for and paid LTD benefits from March 2011 until March 2014, when MetLife notified Roberts that he no longer met the criteria for LTD benefits and that his LTD benefits would be terminated in April 2014. Following a successful appeal, MetLife again approved benefits until May 2015 when MetLife again terminated LTD benefits. Roberts appealed and in May 2016 MetLife upheld its denial. Roberts then filed suit under the Employee Retirement Income Security Act of 1974 (“ERISA”) to recover benefits due to him.

MetLife’s Rationale for Denial

In support of its denial, MetLife contended that the denial of LTD benefits was not an abuse of discretion because Roberts failed to establish that he was unable to perform any gainful occupation after May 2015. Further, MetLife argued that it had advised Roberts that “there were no clinical exam findings nor restrictions or limitations that continued to support an impairment that would preclude Roberts from performing the duties of any occupation.” MetLife argued that the Plan placed the responsibility on Roberts to prove that he was disabled, and that Roberts failed to satisfy his burden.

MetLife stated that it reviewed clinical notes from Duke Medicine, and these notes established that Roberts was able to: (1) run three to four miles, up to seven, every other day; (2) cycle the other days; (3) work out at the gym; (4) take care of his son who has special needs; (5) drive to perform errands and medical appointments; (6) remain functional and social; (7) get out of the house daily; and (8) take care of his elderly parents who live in his house. In addition, MetLife argued that the clinical notes state that Roberts had improved, his pain was tolerable, and that the medication prescribed helped control his pain. Finally, MetLife noted that Roberts suffered no neurological deficits, pain pathology was not demonstrated, and the MRI had no significant findings.

Robert’s Support for Abuse of Discretion 

In claiming that MetLife’s decision was an abuse of discretion, Roberts argued that MetLife failed to properly analyze how Roberts’ symptoms of headaches and pain limited his abilities. He argued that it was unreasonable to require that he produce objective tests or other evidence demonstrating his pain and chronic headaches, and such requirements are “impossible” to meet and not required by the Plan.

Roberts also argued that MetLife had not set forth any jobs that he could actually perform. Further, Roberts noted that, after paying Roberts benefits for over four years, MetLife had not identified any improvement or change in his medical condition that would provide a basis for a denial. Finally, Roberts contended that MetLife did not give appropriate consideration or analysis to the SS Administration’s approval of Roberts’ claim and that MetLife merely inserted the following generic, rote language into its final denial letter: 

However, Social Security Administration’s (SSA) determination is separate from and governed by different standard than MetLife’s review and determination pursuant to the terms of your employer’s plan. MetLife initially approved your claim for benefits for the same time period for which the SSA approved benefits. However, we have updated medical records for which Social Security did not have; we determined this information does not provide clinical evidence supporting continued impairment as described above.

Courts Findings on Evidence and Ruling

The court noted that many LTD policies specifically limit benefits after a certain time period when the condition causing the disability cannot be verified or is based on subjective or self-reported symptoms. Here, however, the limitation provided that after twelve months, a claimant must be unable to perform any occupation. It is silent as to non-verifiable symptoms or subjective or self-reported symptoms. In such a situation, plan administrator may not simply dismiss subjective complaints of pain, especially where there is objective medical proof of a condition that could cause such pain. Specifically, the Court found that a diagnosis that turns on subjective information is not necessarily less debilitating and does not give a plan administrator unbridled discretion to deny such claims.

To that end, in its final decision denying Roberts LTD benefits, MetLife repeatedly acknowledged that Roberts suffers from neck pain and headaches. However, MetLife stated that there were no neurological deficits or significant cervical pathology, and no restrictions or limitations were identified. The fact that the MRI or other tests did not find any abnormalities only rules out certain causes of migraines; it does not conclusively establish whether someone has migraines or not. Due to the subjective nature of migraines, Roberts submitted the best evidence that he could to prove his condition. As for restrictions and limitations, Roberts’ treating physician noted numerous times in his treatment notes that pain limits Roberts’ functioning and Roberts was disabled.

The evaluation of and weight to be given to subjective evidence is largely dependent on the circumstances of a particular case. Here, MetLife could not point to any language in the Plan limiting proof to only objective data. Therefore, the Court concluded considering the language of the Plan and Roberts’ specific diagnoses, by denying Roberts’ claim on the ground that he had not provided objective evidence of his pain, despite his submission of medical reports from multiple physicians stating that his reports of pain were consistent with their diagnoses and that Roberts did not appear to be malingering, MetLife engaged in arbitrary and capricious decision making.

Finally, MetLife argued that it relied on the opinion of its medical consultant, who independently reviewed Roberts’ medical records. In doing so, however, MetLife disregarded the opinion of Roberts’ treating physicians on the severity of Roberts’ condition and his inability to work. Although it is well-settled that a plan administrator is generally entitled to rely on the recommendation of a consulting physician, even when it is in conflict with the opinion of a claimant’s treating physician, a plan administrator may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.

While MetLife’s consultant never personally examined Roberts, his primary care physician has been treating Roberts for over a decade, is a specialist in the relevant field of neurologic disorders, which migraines are classified under, and he has consistently concluded that Roberts is disabled by his chronic and intractable migraines.

The court found it interesting that, in its argument MetLife stated that it had previously accepted Roberts’ medical documents from his PCP and his diagnosis of disability as “true.” Based on the foregoing, the Court found MetLife’s ultimate conclusion and its reliance on its medical consultant’s opinion which contradicts Roberts’ treating physician to be “unreasonable given the absence of contradictory medical evidence and the extent of Roberts’ disability revealed in his medical records and supported by his physicians’ observations and opinions.

This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation of disability insurance benefits.  Please feel free to contact our office and to speak with one of our disability attorneys for a review of your disability insurance policy and to discuss how we may be able to assist you in securing benefits.

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