MetLife’s Denial of LTD Benefits Was Based on Substantial Evidence

The Plaintiff in Patricia Ann McNeal v. Metropolitan Life Insurance Company (MetLife), was employed by Alternative Opportunities, Inc. (Alternative) as a mental health therapist when she fell in January 2014 and injured her left knee. Alternative provided short-term disability (STD) and long-term disability (LTD) insurance coverage to eligible employees.

McNeal was an eligible employee of the benefit plan, which was administered by MetLife. MetLife was also the entity responsible for paying benefits. According to the terms of the policy, for the first 24 months of disability, the plan would pay STD benefits if a claimant was unable to perform “the essential functions You regularly perform that provide Your primary source of earned income.”

After the expiration of STD benefits, in order to qualify for LTD benefits, the claimant had to prove that she was unable to perform “any gainful occupation for which you are reasonably qualified taking into account Your training, education and experience.”

McNeal required surgery on her knee. MetLife approved her claim for STD benefits while she recovered from knee replacement surgery. There were complications and a second surgery was ultimately performed, during which time she still received STD benefits. There were times throughout this period where MetLife would terminate benefits, but when McNeal appealed and provided more evidence, MetLife would grant her appeal and reinstate STD benefits.

After McNeal exhausted her STD benefits, she applied for LTD benefits. Her claim was not approved, and she appealed. The denial was upheld on the administrative appeal, so she filed this ERISA lawsuit in the United States District Court for the Northern District of Oklahoma. She alleged that MetLife improperly denied her claim, and she was entitled to LTD benefits.

The District Court sided with MetLife and held that under the proper standard of review, MetLife did not act arbitrarily and capriciously in denying McNeal’s claim, so McNeal was not entitled to LTD benefits.

No Procedural Irregularity, so Review for Abuse of Discretion was Proper

The District Court noted that when there have been procedural irregularities, de novo review is proper. In the absence of procedural irregularities, “an abuse of discretion/arbitrary and capricious standard of review is applied where the plan gives the administrator discretion to determine eligibility.”

Although McNeal argued that MetLife had improperly classified her job, and the quality and quantity of the evidence was such that de novo review was proper, the Court analyzed both of McNeal’s arguments and disagreed.

Improper job classification. McNeal argued that when MetLife initially classified her job as “light” but later changed it to “sedentary.” The Court concluded that after a review of the complete administrative file, MetLife used the job description provided by her employer. Also, the functional description of her job duties as described in the Dictionary of Occupation Titles was consistent with the job description provided by her employer. Thus, “There was no procedural irregularity regarding the description of job functions and requirements.”

Quality and quantity of the evidence. McNeal argued that since the information provided MetLife was sufficient for STD benefits, it should have been sufficient for LTD benefits. The Court disagreed and quoted from Tenth Circuit precedent that “approval of STD benefits [does] not guarantee approval of LTD benefits. The Court evaluated all the evidence presented by McNeal’s treating physicians as well as MetLife’s reviewing physicians. It also noted that MetLife, on numerous occasions, asked her surgeon, Dr. Gursky, to provide more detailed information about how her physical limitations prevented her from performing her job duties.

MetLife also provided Dr. Gursky with the reports of its reviewing physicians, Drs. Rangaswamy and Freedman, and asked for his response. “[E]ach time Dr. Gursky responded with vague responses, and did not provide medical documentation to support his opinion that McNeal was unable to return to work. He never addressed her specific limitations I in relation to the actual requirements of her job.”

McNeal argued further that MetLife did not provide the reviewing physicians complete information and therefore, their opinions should be “insufficient grounds to deny her LTD benefits.” The Court disagreed and noted that MetLife “repeatedly requested medical evidence tying McNeal’s knee issues to an inability to do the physical requirements of her job as a clinician during the elimination period, and the evidence was not provided.”

The medical information provided indicated that McNeal was progressing and able to perform many personal activities independently. She was able to drive, go to church twice a week, and perform household chores. “The information Dr. Gursky provided included only his general opinion that McNeal should be considered for LTD benefits, without referencing her actual abilities during the specific, relevant time frames, and he did not address the specific time-frames during which independent physicians concluded Ms. McNeal’s medical condition would not prevent her from doing her job duties.”

MetLife had a conflict of interest. The Court also considered the conflict of interest by MetLife, which acted as both the payer of benefits and evaluator of whether a claimant was entitled to benefits because it found the evidence did not support a claim that the “conflict affected the benefit decision.” The Court noted that MetLife had the medial file reviewed independently twice, both times by Board Certified Orthopedic Surgeons, “both of whom came to similar conclusions that the record was lacking any evidence indicating that McNeal was continuously unable to perform her job duties during the relevant 180-day time period.” Because of this review, the Court gave less weight to the conflict of interest claim.

Court Held MetLife Did Not Abuse its Discretion in Denying McNeil LTD Benefits

In reviewing the entire administrative record, the Court found in relationship to the application for LTD benefits, MetLife repeatedly asked for more information from McNeal’s orthopedist and treating physician and asked him to respond to the two reviewing physician reports. All MetLife received were “vague responses.” Dr. Gursky never addressed her specific limitations in relation to the actual performance of her job.

The reviewing physicians made their medical conclusions based on the information that was provided to them, which was the medical information provided by McNeil’s treating physician. Even so, “ERISA does not require a claims decision-maker accept the opinions of the claimant’s treating physician over the opinions of other medical professionals, as long as the opinions relied upon are supported by evidence.”

The Court concluded, “Based on the record and having considered the parties’ submissions and arguments, the Court finds that MetLife’s denial of LTD benefits was made on a reasoned basis and was supported by substantial evidence… MetLife’s decision to deny McNeal LTD benefits was not arbitrary and capricious.”

If you need to file a claim for STD or LTD benefits, or have questions about a pending claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

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