Kathleen Bernardo was employed by American Airlines as a Manager of Airport Services. Bernardo was diagnosed with aplastic anemia and was treated with cyclosporin A and prednisone. Bernardo sought long-term disability benefits under the Plan for which MetLife was the administrator. Bernardo’s claim for long-term disability benefits included a letter from Dr. Rice, Bernardo’s treating physician, stating that she was unable to work “due to severe pansytopena and side effects of medication, including profound fatigue, tremors, and nausea.” Based on this information, MetLife determined that Bernardo was totally disabled and approved long-term disability benefits. However, MetLife later re-evaluated Bernardo’s claim and decided to deny Bernardo’s long-term disability benefits because the records “did not substantiate that she was totally disabled.” Bernardo sued under the Employee Retirement Income Security Act of 1974 (ERISA).
MetLife’s denial letter addressed Bernardo’s aplastic anemia and cataracts, but did not mention her cyclosporin A neurotoxicity covered in her doctors’ reports. The Court found it “impossible to reconcile” the report of MetLife’s doctor with the reports of Bernardo’s doctors. MetLife’s doctor did not purport to explain why the severe symptoms found by the treating doctors were not disabling. “This is not a situation in which the reviewing physicians reached a different medical conclusion from the medical evidence in a claimant’s file or where other evidence of the claimant’s condition contradicts the diagnosis of the treating physician,” the Court reasoned. Because the plan administrator and the reviewing physicians did not present specific evidence that contradicted the treating physicians’ conclusion that Bernardo “is 100% disabled from work, and likely has been since the onset of Cyclosporin A usage”, the Court held that MetLife had abused its discretion in denying long-term disability benefits to Bernardo.
This case involved the common abuse by long-term disability carriers in denying benefits without first addressing or refuting the medical evidence presented by the claimant’s treating doctors.
