In the case of Robert Gordon v. Metropolitan Life Insurance Company (MetLife), Plaintiff was a Senior Staff Systems Programmer with Borland Software Corporation from 1989 until he was fired on May 1, 2002. He suffered from a multitude of psychological and physical conditions including depression, anxiety, and post-traumatic stress disorder (PTSD). He claimed these problems were all due to harassment and threats he received from his immediate supervisor. He also suffered from spinal, knee, and shoulder injuries.
On April 19, 2002, his physician ordered him to take one week off work. Plaintiff did not return to work until May 1, 2002. On that same day, he was fired due to performance issues.
Summary of the Underlying Facts
On October 22, 2009, several years after he was fired from his job at Borland, Plaintiff filed a claim for long term disability (LTD) benefits dating back to April 19, 2002. He listed a myriad of problems along with a note from a treating physician which stated Plaintiff had “disabling back & neck pain for degenerative disc disease, chronic migraine headaches and failed knee and shoulder surgery since February of 2002.”
The claim was denied, so Plaintiff requested an administrative appeal. On appeal, his claim was again denied. His disability insurancecarrier, MetLife informed him that he had coverage under its policy through May 1, 2002. But, the medical information provided did not support a finding of disability during the time he was eligible for coverage.
The ERISA lawsuit, which had been filed prematurely and stayed while MetLife considered the administrative appeal, proceeded and both parties filed Motions for Summary Judgment. The Court conducted de novo review and held in favor of MetLife, finding that Plaintiff did not prove by the preponderance of the evidence that he was disabled during the time he was covered by the MetLife policy.
Plaintiff Was Ineligible for Benefits Under the Terms of the Policy
According to the MetLife policy terms, in order to receive LTD benefits, Plaintiff must have met certain eligibility requirements prior to May 1, 2002, the date of his employment termination. He must have been disabled to a degree that he was unable work in his own occupation for any employer in the local economy. Specifically, the relevant clauses include:
Definition of disability. “Disabled” means that “due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis.” Appropriate Care means medical care that meets all the following:
· It is received by a medical professional whose training and experience are suitable for treating the claimant’s disability.
· It is necessary to meet the claimant’s basic health needs.
· It is consistent in type, frequency, and duration of treatment.
· It is consistent with the diagnosis.
· Its purpose is to maximize claimant’s medical improvement.
In addition, the claimant’s loss of earnings “must be a direct result of [the claimant’s] sickness…”
Income loss. The policy states: “During your Elimination Period and the next 60 month period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own occupation for any employer in your Local Economy.”
The United States District Court for the Northern District of California, San Jose Division, conducted de novo review of Plaintiff’s claim and analyzed in detail the reports of 12 physicians who had treated him over the course of several years. The Court also reviewed details of three physicians who conducted a review of the medical record on behalf of MetLife.
The Court determined Plaintiff was not entitled to LTD benefits stating:
“Having conducted a de novo review, the Court finds that the Plan correctly determined that Plaintiff was not “Disabled” from performing his “own Occupation” prior to his May 1, 2002 termination date. Although the Administrative Record confirms Plaintiff suffered from multiple medical conditions prior to May 1, 2002, the medical records fail to establish (1) that Plaintiff was receiving care and treatment for any of those medical conditions on a continuing basis and (2) that during the Elimination Period and the next 60 month [sic] period Plaintiff was unable to earn more than 80% of his Earnings or Indexed Predictability Earnings at his Own Occupation for any employer in his Local Economy.”
For these reasons, the Court held that Plaintiff was not entitled to LTD benefits since he had not met his burden to prove that while he was covered by the Plan, which was prior to May 1, 2002, he was disabled within the meaning of the Plan.
This case was not handled by our office, but we feel it is instructive to those who may have a similar issue. If you have any questions about your disability claim, contact one of our attorneys at Dell & Schaefer for a free consultation.