MetLife must reconsider denial of benefits for former MetLife employee

A recent short-term disability case before the United States Court of Appeals, Seventh Circuit, Chicago, Ill., demonstrates that insurance companies are no friendlier to their own employees than anyone else. Kirsten Majeski worked for Metropolitan Life Insurance Company (MetLife) as a nurse consultant until June 2006 when she began complaining of pain and numbness in her shoulders, arms and hands. She was diagnosed with cervical radiculitis, a disorder of the spinal nerve roots.

MetLife denies disability claim

As a participant in MetLife’s short-term disability plan, she applied for disability benefits. Her initial application was approved temporarily, but in August, MetLife reversed its decision claiming that her medical records failed to objectively establish that she had any functional impairment that would prevent her from continuing her work as a nurse consultant.

She obtained new, detailed medical evidence from her treating rehabilitation specialist, Dr. David Weiss, who completed a five-page cervical spine residual functional capacity questionnaire. The general consensus of the questionnaire demonstrated significant impairment for the duties of Majeski’s job.

This wasn’t the only information that Majeski produced. She also provided a physical work performance evaluation conducted by a physical therapist, Susan Hardin. Based on this 36-point test, Hardin concluded that Majeski could not type for more than 8-1/2 minutes without experiencing significant pain and the typical sitting of a sedentary job aggravated her condition significantly.

Metlife requests review of medical records

MetLife requested an independent review of Majeski’s medical records from Dr. Phillip Marion, a board certified physical medicine, rehabilitation and pain management specialist. On March 1, 2007, Dr. Marion advised MetLife that there were “minimal objective findings on physical and neurological examination” to support Majeski’s claim that her functional limitations prevented her from completing the tasks expected of a nurse consultant. In his evaluation, he acknowledged Hardin’s conclusion that Majeski could perform non-sedentary (medium) work, but did not indicate that he had considered Hardin’s conclusions that Majeski had limitations for sitting and typing which would prevent her from working as a nurse consultant. Nowhere in his report did he mention Dr. Weiss’ five-page functional capacity questionnaire.

MetLife forwarded Dr. Marion’s reports to Dr. Weiss on March 28 and asked him to respond by April 10. The response from Dr. Weiss on April 6 was brief, he said, “I disagree with the decision of Dr. Marion,” and made no further comments.

MetLife also alerted Majeski’s counsel of the April 10 deadline. MetLife received a fax on April 12 questioning the unbiased nature of Dr. Marion’s decision from Majeski’s counsel. Council also raised the question of a 200 page deposition in an unrelated case that revealed Dr. Marion’s predisposition to rule in favor of employers and against short-term disability applicants. A CD containing the deposition was mailed on the same day.

It is unclear whether MetLife had received the CD on April 18, but the insurance company determined that Majeski was not disabled. It based its decision on Dr. Marion’s conclusion that Majeski’s medical records failed to support her claim of functional impairment.

Because Majeski would have been required to apply for Social Security disability benefits under the terms of her short-term disability policy if she had been approved, she submitted an application to the Social Security administration in May 2007. Social Security administration ruled in her favor in March 2008. Based on this favorable ruling, Majeski sued MetLife in federal court claiming the denial of disability benefits fell under ERISA.

District Court Rules in favor of MetLife

Majeski argued for a heightened standard of review claiming metLife had a conflict of interest being both the plan administrator and the payer of benefits. But the district court chose to consider the case under the arbitrary and capricious standard. The court did consider evidence that Dr. Marion had an ongoing financial relationship with MetLife but came to the conclusion that there was no evidence that Dr. Marion demonstrated a predisposition to rule against short-term disability applicants and in favor of the insurance company. The District Court issued summary judgment for MetLife and ruled against Majeski.

Majeski appealed, seeking to require the court to consider her approved application for Social Security benefits, even though it was not part of the administrative record. She also sought to have the evidence supporting Dr. Marion’s bias against disability applicants entered into the record. The Appeals Court agreed with the District Court’s decision, and chose not to consider this information in their decision.

But the Appeals Court did find it troubling that MetLife made its decision based on one doctor’s report. They found that Dr. Marion’s report failed to recognize the objective evidence that she had provided. He did not mention Dr. Weiss’ questionnaire, and it was not listed under the documents that MetLife sent to him for review. He also did not address the fact that Hardin explicitly said that Majeski could not sit or type, major duties of her job as a nurse consultant.

Appeals Court orders MetLife to reconsider case

By ignoring and dismissing evidence in the functional capacity evaluation, MetLife demonstrated arbitrary and capricious action in its decision. Plan administrators are not allowed to simply ignore a treating physician’s medical conclusions or to dismiss an expert’s conclusion without providing an explanation.

Because MetLife obviously ignored Majeski’s key medical evidence, the Appeals Court concluded that Majeski had not received a full and fair review. The company also failed to address the evidence she had provided and why it was inadequate to support her claim. MetLife claimed that Majeski had failed to prove her functional limitations. The documents that she supplied suggested otherwise.

While Majeski would have preferred the court rule directly in her favor, in this situation, the Appeals Court chose to send her case back to MetLife for reconsideration. The Court found the evidence in the record was not persuasive enough to justify ruling in Majeski’s favor outright.

Depending on how MetLife handles this case now that it has to consider it again, Majeski may find herself in court again.

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