Another case appeared in the U.S. Court of Appeals that highlights the importance of exhausting all the administrative options available before taking a case to court. Additionally, this case demonstrates the importance of a treating physician responding to all requests from a disability insurance company.
What happened here? And what can you learn from this case that could help you win your claim for disability insurance benefits?
First, we will look at the history of the case. Then we will look at the law as the court interpreted it.
Luis Medina was a maintenance technician at the Puerto Rican Abbott Laboratories, Inc. facilities. He participated in the disability insurance plan administered by Metropolitan Life Insurance Co. (MetLife) for his employer. When he was diagnosed with obstructive sleep apnea and high blood pressure in June of 2006, he quit working and applied for short-term disability benefits.
Along with his application, he provided a diagnostic report prepared by his treating physician. On August 1st, MetLife granted Medina short-term disability benefits for a limited period, but the insurance company made it clear that additional documentation confirming that Medina truly qualified for disability payments would be required.
Medina’s doctor submitted a second evaluation on August 21st. It contained additional diagnoses but minimal test results to verify the how these diagnoses would impact Medina’s ability to work. MetLife made several attempts over the next two months to reach Medina and his doctor. While they did make contact with Medina, his attending physician responded to neither the letters, faxes nor phone calls from MetLife. Medina said he would speak with his doctor.
Finally, on November 13, 2006, MetLife received a progress report from Medina’s doctor covering the time from June 4 through August 16. It was based on the quality of this progress report that MetLife issued a letter in December terminating Medina’s short-term disability benefits. In brief, here is what they indicated was missing:
- Medina claimed to have high blood pressure. The doctor’s notes indicated readings within the normal range.
- Medina’s doctor indicated that Medina was on a weight loss plan. There were no details about the plan such as starting weight or progress reports, or even why the weight loss plan was needed.
- Medina’s doctor had diagnosed congestive heart failure, but there was no supporting evidence such as an electrocardiogram, finding from a medical exam or X-rays.
- None of the notes provided any details about physical or functional limitations that would prevent Medina from working as a maintenance technician.
Medina appealed MetLife’s decision in late December 2006. MetLife agreed to submit the claim to an independent medical consultant. On January 7, 2007, Medina forwarded additional progress reports from his doctor and more details were supplied about the symptoms Medina was experiencing and the diagnoses and treatments being used. With this information added to the file, MetLife referred the entire claim file as agreed for independent review.
On January 31, 2007 the review came back. Met Life’s doctor found that there were insufficient clinical findings and too little data to support Medina’s claim. The physician just couldn’t find enough evidence to support Medina’s inability to return to the duties of his position. Two days later, on February 2, MetLife faxed a copy of the report to Medina’s doctor asking him to provide evidence if he disagreed with the findings in order to disprove them. The doctor claimed he didn’t receive it.
Meanwhile MetLife also called Medina repeatedly, asking him to relay the message to his doctor that they were trying to reach him. Medina kept telling MetLife that he had relayed the message and that his doctor was getting upset, because he didn’t have anything more to send.
Mid-March rolled around. MetLife was still waiting on a response from Medina’s doctor. On March 21, 2007, the insurer finalized its review of the file and concluded that there was no evidence that supported reversing the denial of benefits. Medina was notified of the decision and that he had exhausted all available administrative remedies.
On April 12, Medina wrote MetLife requesting all relevant documents on which it had relied in reaching its decision. He specifically asked for a copy of the fax sent to his doctor, along with the confirmation page demonstrating that it had been transmitted successfully. Within a week, he had the entire file minus the transmittal sheet.
Medina sued MetLife for denial of short-term and long-term disability benefits in Federal District Court for the District of Puerto Rico, filing a motion for judgment on the administrative record. District court reviewed the administrative record and found that MetLife had not abused its discretion in denying Medina’s claim. As a result the court denied Medina’s motion and granted summary judgment to MetLife. Medina appealed.
The U.S. Court of Appeals conducted a de novo, or fresh, review of Medina’s case. The Court looked for evidence that MetLife had been arbitrary or capricious in its decision. They found that MetLife’s decision had been reasoned and supported by the evidence (or in this case lack of it).
Medina claimed that the evaluation by the independent consultant was based on false information, as indicated by the description of Medina’s job duties being “medium work.” This point had not been raised during the month and a half that MetLife had tried to reach Medina’s doctor, or during the claim in district court. The Appeals Court would not consider the argument.
Medina claimed that MetLife had failed to give sufficient weight to his attending physician’s evaluations. The Appeals Court disallowed this argument as well, stating that case law does not require the administrator to give more weight to the attending physician’s evaluations. Especially in the presence of contradictory evidence, the administrator is entitled to exercise its discretion.
The court also found that the independent doctor’s review offered substantive reasons for offering a contrasting view. He cited the many diagnostic tests that were not present in the record. He also pointed out that it is very rare for sleep apnea to cause impairment.
Finally, Medina claimed that MetLife was required to wait until they received his doctor’s feedback on the independent report before making a final decision. MetLife claimed to have sent the fax, which was present in the administrative record. Medina claims it was never received and the very fact that it was sent proved that it was deemed necessary by MetLife. Medina claimed a decision made without that information was inherently arbitrary and capricious.
The Court didn’t buy the argument. The record indicated that Medina had ample notice that MetLife was seeking more detailed information and was actively trying to contact his physician. The Court saw no reason why MetLife should be held hostage by a physician who did not reply to their communications, especially when the law didn’t even require them to give special weight to his findings. The fact that his doctor did not supply comment or additional information, validated Medina’s claim that the doctor was upset and had nothing further to say. When the fact that Medina had the fax in hand shortly after the denial of benefits was considered, failure to present supporting evidence to refute the report didn’t assist Medina’s argument either.
Medina had also included a claim for denial of long-term disability insurance. District court required him to present proof of his application. He had not done so, and at the time of appeal, still could not produce anything but circumstantial proof of having done so. The court ruled that the district court was correct in finding that Medina had failed to exhaust his administrative remedies with regard to his long term disability claim.
Medina’s case didn’t go well for him for two reasons. He failed to provide the information needed to demonstrate the nature and severity of his disability. And he failed to apply for long-term disability before he filed a lawsuit. Unfortunately, Medina did not have a cooperative physician, and therefore he never stood a chance of winning his claim for disability benefits.