Case Conclusion Date: September 30, 2010
Practice Area: Employee Benefits
Outcome: Client won LTD benefits
Description: A. MetLife Improperly Ignored Social Security Decision. The Court held that the Social Security decisions would be persuasive evidence that Jayce was disabled as required by the Plan, because, the Social Security standards are more stringent in this instance. “Moreover, the Supreme Court has found questionable MetLife’s conduct in requiring a claimant to argue to the Social Security Administration that she could do no work, and then ignoring the agency’s finding in concluding that the claimant in fact could do sedentary work”, said the Court. B. Proof Of Disability. The Court found it “undisputed” that Jayce fell in the manner claimed, and that he suffered disc desiccation, broad-based disc bulge, and disc protrusion at L4-5. Five different physicians that either treated or examined Jayce opined that he had significant limitations on sitting and standing and “[c]hronic disabling lumbar pain of probably diskogenic etiology”. The Court said that it was, “at a loss to imagine how [Jayce] could perform his own occupation, which undisputedly consisted primarily of sitting in front of a computer, if he could not sit.” It was also found significant that none of the physicians expressed doubts as to the degree of pain reported by Jayce; there was no suggestion that he was malingering. C. MetLife Relied On Mere Paper Review. The only doctors who suggested that Jayce did not suffer disabling pain were the two doctors hired by MetLife, Drs. Smith and Turok. Neither Dr. Smith nor Dr. Turok ever met or examined Jayce; thus neither had any opportunity to assess his credibility. The Court concluded that under these circumstances, it was an abuse of discretion for MetLife to reject Jayce’s subjective pain complaints and, based upon that rejection, to discount the medical opinions that credited those complaints. While a plan administrator is not required to subject the claimant to an in-person medical examination, in performing the abuse of discretion analysis the Court may consider the fact that the administrator relied upon a paper examination. MetLife’s hired doctors focused on Jayce’s “refusal” of a lumbar epidural steroid injection and/or surgery. However, as noted by the Court, MetLife did not point to any evidence that agreeing to a steroid injection and/or surgery were the only reasonable medical decisions that Jayce could make. D. MetLife Abused Its Discretion. In considering the administrative record as a whole, including the consistency of Jayce’s pain complaints from the time of his fall onward, the MRI demonstrating a disc injury, the opinions of five different doctors who treated or examined Jayce, the absence of any evidence of malingering, the fact that Drs. Smith and Turok did not examine Jayce, and the fact that MetLife has an inherent conflict of interest because it both administers and funds the Plan, the Court concluded that, “MetLife abused its discretion in denying [Jayce’s] claim for benefits.” Conclusion. MetLife’s abusive practices are in my opinion systemic and nationwide. Three recent court decisions provide for full remedies and attorney fees but, until punitive damages are allowed under ERISA claims like this, I expect MetLife to continue its abuse of the disabled with impunity.