In Monroe v. Metro. Life Ins. Co., 2020 WL 143005 (E.D. Cal. March 24, 2020), Plaintiff worked for Kaiser Foundation Health Plan, Inc. (“Kaiser”) until 2014 when chronic lumbar back pain caused her stop working. She applied for long term disability benefits (LTD) but was denied. Plaintiff hen filed suit under the Employee Retirement Income Security Act of 1974 (“ERISA”) to recover benefits due to her.
At the time of the onset of her disability in March 2013, Plaintiff’s job title was Human Resources Compliance Specialist. Her position entailed substantial data entry, requiring that she sit continuously for long periods at a computer, typically 98 percent of her eight-hour workday.
The Plan defines Totally Disabled or Total Disability as: “[d]uring the Elimination Period and the next 24 months, you are unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue Your Usual Occupation in the usual and customary way.” “Usual Occupation” is defined as: any employment, business, trade or profession and the Substantial and Material Acts of the occupation you were regularly performing for the employer when the Disability began. Usual Occupation is not necessarily limited to the specific job that you performed for the employer. And finally, “Substantial and Material Acts” are defined as “the important tasks, functions and operations generally required by employers from those engaged in your Usual Occupation that cannot be reasonably omitted or modified.”
After recounting Plaintiff’s extensive medical treatment history and significant objective test results (e.g., MRI’s, Straight Leg Raise Test) and clinical findings that supported her impairment, the Court noted that the De Novo review standard applied and under that standard “the plaintiff carries the burden of showing, by a preponderance of the evidence, that she was disabled under the terms of the Plan during the claim period.” Simply put, was Plaintiff disabled from performing her regular occupation under the applicable MetLife long-term disability plan.
Courts Findings on Evidence
On that issue, the Court found the preponderance of the evidence supports the conclusion that Plaintiff was disabled from her usual occupation. Plaintiff’s medical records show the deterioration of her physical health and abilities over the course of the elimination period and thereafter. And her treating physicians resolved that Plaintiff could not sit for more than two non-continuous hours per day and she could not stand on her own. These restrictions ensured that Plaintiff could not perform her duties as a Human Resources Compliance Specialist, which required her to sit at a computer for approximately 98 percent of her eight-hour work day. The Court made a point to note that none of Plaintiff’s doctors indicated that they believed she was exaggerating her pain levels or that she showed any signs of being a malingerer.
The Court first addressed the opinions of MetLife’s hired medical records review consultant, Dr. Hinrichs, which it relied so heavily on to deny Plaintiff’s claim. In response to his opinion that Plaintiff’s conditions should not have caused her enough pain to hamper her ability to work a sedentary job, the Court found:
[Dr. Hinrichs’] report does not assert or establish that it is impossible for a patient with conditions such as Plaintiff’s to experience a debilitating amount of pain. Nor does the report coincide with any opinions on the part of Plaintiff’s treating doctors that would call Plaintiff’s reports of pain into question. Dr. Chiang, Plaintiff’s treating doctor since 2010, wrote an opinion letter which refuted Dr. Hinrichs’ position and corroborated Plaintiff’s reports of pain and her inability to perform her occupation due to her back pain.
The Court then refutes Dr. Hinrichs’ opinion that various physical work activities would be appropriate for Plaintiff despite her chronic low back pain:
Dr. Hinrichs does not point to Plaintiff’s specific complaints, nor to the portions of her medical records that would support the specific restrictions he indicates are appropriate for her. Instead, Dr. Hinrichs appears to set forth as opinion the generalization that a person with Plaintiff’s conditions would be so limited or so able. This is not a well-supported conclusion as Defendant contends. Indeed, Dr. Hinrichs simply summarized the medical records he reviewed and then made a conclusion. He did not indicate which medical records supported his conclusion that Plaintiff should be able to perform her sedentary occupation, nor did he comment on Plaintiff’s subjective report of pain and her inability to sit for any extended period of time.
Next, addressing the fact that neither of MetLife’s medical records reviewers, Dr. Hinrichs and Nurse Bachner, physically observed, examined or treated Plaintiff, the Court noted:
While Defendant is correct in its assertion that treating physicians are not accorded any special deference in ERISA cases, the Court may still evaluate the relative weight of reviewing physicians based on their opportunity to evaluate the plaintiff. The weight given to an examining doctor’s conclusions and diagnosis is based upon: (i) the extent of the patient’s treatment history; (ii) whether the examining physician specializes in the condition at issue; and (iii) how much detail the examining physician provides to support his conclusions. Here, Plaintiff’s treating physicians have long histories of treating Plaintiff for her numerous ailments. Over the years, they were able to interact with Plaintiff and make observations as to her functionality, pain levels, and ability to work. All these doctors were working towards her recovery and made notes reflecting fluctuations in her status. The opinion letters written by [her physicians] were detailed and based upon their personal observations of Plaintiff as well as her medical records from other doctors. The Court finds these doctors’ opinions to hold significant weight in determining Plaintiff’s ability to qualify for benefits under the Plan.
The Courts Ruling
Not only does the Court conclude that Dr. Hinrichs failed to support his purported restrictions with specific reference to the medical record, he also completely disregarded the notations in Plaintiff’s records that she is unable to stand unassisted. In fact, Dr. Hinrichs made a point of stating that he does not believe the medical information as presented is objectively supportive of impairment or restrictions. This, coupled with the information Dr. Hinrichs included from Plaintiff’s medical records in his initial report, suggested that Dr. Hinrichs incorrectly disregarded Plaintiff’s subjective reports of pain and only focused on what he deemed to be “objective.” Plaintiff’s subjective complaints of pain were validated by clinical tests and observations made by the treating doctors, as well as MRI findings showing progression of Plaintiff’s spinal degeneration. For these reasons the Court criticized MetLife for failing to conduct an independent medical examination, which it had the power to require under the Policy. The Court noted, “[a] single in-person examination would have gone a long way in allowing MetLife to assess Plaintiff’s credibility and level of pain.”
Finally, the Court acknowledged the difficult task of administrators who must weigh evidence as they receive it and determine the credibility of disability claimants. For example, the Court acknowledged that records of Plaintiff’s numerous medical visits may not have been available immediately to MetLife during its initial claim review. Despite this difficulty for administrators, the Court found Plaintiff to be a credible witness. Plaintiff worked for years with back pain and only ceased working after the pain increased substantially. Further, Plaintiff attempted to return to work and did so successfully for a period or time, despite the onset of additional debilitating medical conditions. Even when her pain proved too intense to continue work, Plaintiff did not initially seek LTD benefits retroactively, but instead sought to file a new claim beginning. It was only due to MetLife’s policy limitations that Plaintiff was required to appeal her initial claim instead of filing a new one. Thus, the Court concluded, Plaintiff is precisely the employee to whom ERISA protections should apply.
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.