The claimant, Mr. Judge, had a high school education and worked for 20 years as a baggage handler and ramp agent for a major airline. He applied for disability benefits under the group insurance policy (the Plan) which was provided by his employer and issued by MetLife. MetLife determined that Mr. Judge was not totally and permanently disabled under the terms of the Disability Plan and denied benefits. Mr. Judge exhausted the internal administrative remedies available to him and subsequently filed his ERISA lawsuit against MetLife. The Michigan district court granted judgment on the administrative record in favor of MetLife and Mr. Judge then appealed to the United States Circuit Court of Appeals, arguing that MetLife’s decision to deny disability benefits was arbitrary and capricious.
The Facts of Mr. Judge’s MetLife Long Term Disability Insurance Claim
The MetLife Plan defined total and permanent disability as: “because of a sickness or an injury”¦ you are expected to never again to be able to do: your job; and any other job for which you are fit by education, training or experience.” Additionally, the Plan required that Mr. Judge send proof that he was totally and permanently disabled and that such total and permanent disability has continued without interruption.
Mr. Judge contends that he is totally and permanently disabled as a result of undergoing surgery to repair an aortic valve and a dilated ascending aorta. He submitted to MetLife, in support of his disability, several post-surgery reports from his treating physicians, Drs. Deeb, Patel and Harber, letters between several of his physicians which documented his post-surgery progress, as well as MetLife’s Attending Physician Statement forms completed by Dr. Deeb and Dr. Harber.
The post-surgery reports and letters between his treating physicians made reference that Mr. Judge was “doing well”, was “awake, alert, oriented, and neurologically intact”, and that he was “up and about, freely mobile.” Dr. Deeb commented that Mr. Judge could “increase his activity”, but was restricted to lifting no more than 15 pounds. Dr. Patel also commented in one of his letters that Mr. Judge could “gradually increase his lifting, pushing, and pulling to [a] maximum of 50 pounds”, and that he could “participate in mild-to-moderate intensity level aerobic activities.” Dr. Patel also noted at that time that Mr. Judge required an additional six weeks off of work to complete his physical therapy.
Dr. Deeb completed a form Attending Physician Statement and filled in boxes which indicated that Mr. Judge was restricted to 2 hours of intermittent sitting and zero hours of standing or walking per day. He checked another box which indicated that Mr. Judge was restricted from reaching above shoulder level, climbing, twisting, bending or stooping, but was able to operate a motor vehicle. He offered no other explanation for these restrictions beyond checking off the boxes on the form. In response to a question, “In your opinion, why is patient unable to perform job duties?”, Dr. Deeb wrote, “Lifting restriction 30 to 35 lbs.” However, Dr. Deeb also indicated on the form that Mr. Judge was able to work eight hours per day, that only his lifting restriction was unlikely to improve, and that his cardiac capacity was “Class2 (Slight Limitation)”.
Similarly, Dr. Harber completed the Attending Physician Statement and filled in boxes which indicated that Mr. Judge was restricted to two hours of intermittent sitting and zero hours of standing or walking per day. He also indicated that Mr. Judge could not reach above shoulder level, climb, twist, bend or stoop, but that he was able to drive. Dr. Harber noted that Mr. Judge was unable to perform his job duties because he could not lift anything over 30 pounds. However, he also indicated that Mr. Judge was able to work eight hours per day, that all areas were expected to improve except for the lifting restriction, and that his cardiac capacity was “Class 2 (Slight Limitation)”. Dr. Harber further noted on the form that he based his work restrictions on Dr. Deeb’s recommendation.
MetLife had a nurse consultant review the medical records and she noted inconsistencies between the earlier post-surgery reports and letters, and the two Attending Physician Statements. She determined that there was no medical evidence within the records which supported the work restriction of no sitting, standing or walking. Based on the nurse’s findings, MetLife denied Mr. Judge’s claim indicating that he was able to perform at least light duty work activities and that he did not provide “objective medical documentation” to support the work restrictions indicated by his physicians.
The initial denial letter stated that Mr. Judge could appeal the adverse decision and submit additional documentation in support of his appeal. Mr. Judge appealed, however, his Michigan disability attorney indicated that there was not any updated medical documentation and that he relied upon the information and statements from his treating physicians that were previously submitted. Accordingly, a second nurse consultant reviewed the medical records and noted that no additional medical information had been provided. She also determined that Mr. Judge was recovering from his surgery as expected and that improvement was expected in all areas except for the lifting restriction. Based on this, MetLife upheld its initial denial of benefits.
In its second denial letter, MetLife states that the post-surgery medical records reflect that Mr. Judge improved after his surgery. They further state that it was not clear why Dr. Deeb and Dr. Harber imposed the work restrictions of no standing or walking, and only sitting for two hours, because there was no medical information provided that indicated Mr. Judge developed other medical conditions or suffered a relapse or complications after his surgery that would have decreased his functional capacity which was determined based on Dr. Patel’s previous assessment. Mr. Judge did not provide any records which supported that he was not regaining additional function for performing work activities and, as such, he did not meet the Plan’s definition of being permanently disabled.
Michigan Court Finds that Mr. Judge Failed to Provide Proof to Support His Claim for Disability Benefits
Three important authorities were relied upon by the Court when evaluating MetLife’s decision to deny Mr. Judge’s disability benefits. The first states that the overall issue in ERISA cases is not whether “discrete acts” by the plan administrator, in this case MetLife, were arbitrary or capricious, but whether the ultimate decision to deny benefits was unreasonable and not supported by the evidence found in the administrative record. The second authority states that it is not unreasonable to require a claimant to provide objective medical evidence of their claimed disability. The third states that it the burden of the claimant to establish or prove his disability and it is not the burden of [MetLife] to show that the claimant is not disabled.
The Court in this matter notes Mr. Judge’s argument that he is totally and permanently disabled under the terms of the Plan and that MetLife failed to consider the fact that Mr. Judge’s only work experience is heavy lifting, which he is no longer able to perform. However, under the terms of the Plan, Mr. Judge is not entitled to benefits based on the fact he is unable to perform similar work to that which he performed prior to the surgery. Rather, he must show that he can never again perform any work for which he is fit by education, training or experience.
The Court determined that MetLife properly denied Mr. Judge’s claim for disability benefits because Mr. Judge did not provide any objective medical evidence which supported that he was permanently unable to sit, stand or walk, and was thereby prevented from performing some other job for which he was fit by education, training or experience. Both the Court and MetLife recognized that Mr. Judge would never again be able to lift heavy objects, such as luggage. However, all of the records reflected that Mr. Judge was either anticipated to, or could already, return to work for 8 hours per day, and Mr. Judge even conceded that Dr. Deeb did not find him permanently precluded from returning to work.
Although Drs. Deeb and Harber submitted Attending Physician Statement forms which restricted Mr. Judge to no standing or walking and only two hours of sitting per day, the doctors only checked off the pertinent boxes on the form and did not provide any further explanation or documentation to support such extreme restrictions. The initial denial letter MetLife sent to Mr. Judge put Mr. Judge on notice that MetLife required “objective medical documentation” supporting the work restrictions in order for his claim to be approved on administrative appeal. Mr. Judge did not request for his treating doctors to provide an explanation for why they imposed the work restrictions, nor did Mr. Judge submit any additional or updated medical information for MetLife to consider upon appeal.
The Court determined that the administrative record was indeed lacking any detailed clinical or diagnostic evidence to support the work restrictions provided by Drs. Deeb and Harber and found that MetLife’s adverse decision was based on substantial evidence and was, therefore, not arbitrary or capricious.
Other Arguments that MetLife’s Decision was Arbitrary and Capricious
Mr. Judge made several other arguments to establish that MetLife’s decision to deny his disability benefits was arbitrary and capricious. He argued that MetLife applied the wrong definition of disability. MetLife admitted that it stated the incorrect definition in its initial denial letter. However, the error was corrected during the administrative appeal and MetLife referred to the correct definition in its second denial letter. The Court determined that it is the final decision that was being reviewed in this matter. It found that the second and final denial letter did in fact state the correct definition and, considering the letter as a whole, it was apparent that MetLife applied the proper definition throughout. The Court further notes that, even if it was determined that MetLife did apply the incorrect definition of disability, a remand back to MetLife for reconsideration under the correct definition would be to no avail because the administrative record clearly lacked the objective medical evidence to prove that Mr. Judge was disabled and could not perform any job for which he was fit by education, training or experience.
Mr. Judge argued that MetLife should have consulted with a vocational expert and provided a job analysis in light of his lifting restriction, that MetLife failed to send him for an independent medical examination or have a cardiologist review his records and that it was improper to have a nurse review his records, and that a conflict of interest existed because MetLife both determines eligibility and pays out benefits. The Court, however, cited to well-established case law which discounts all of these arguments and found that MetLife’s decision to deny disability benefits to Mr. Judge was supported by the evidence and was not arbitrary and capricious.
Attorneys Dell & Schaefer did not handle this claim, but it appears that a lot more could have been done at the ERISA APPEAL level in order to have a much better chance of reversing the MetLife claim denial. If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to contact Disability Attorneys Dell & Schaefer for a free consultation.
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