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MetLife Denied Claimant Full and Fair Review

In another victory for a disabled individual today, the Seventh Circuit Court of Appeals vacated a lower court's decision. In this case, the claimant, "Kirsten", sued MetLife in federal court, challenging the denial of her disability benefits under the Employee Retirement Income security Act of 1974 (ERISA). The Appeals Court refused to "rubber-stamp" MetLife's denial of Kristen's long term disability benefits. The Court found it troubling that Dr. Marion's report-the sole basis for MetLife's determination-concluded, erroneously, that Kirsten did not submit objective evidence of functional limitations.

As is too often the defect in MetLife's claim decisions, Dr. Marion did not acknowledge, much less analyze, the significant evidence of functional limitations that Kirsten offered. Dr. Marion ignored Dr. Hardin's conclusion that Kirsten was incapable of typing and sitting. Accordingly, the Court held that "Dr. Marion's statement that Hardin's evaluation 'does not document, nor is it reasonable to conclude from it, that the claimant has functional limitations that precluded sedentary work activity requiring sitting, using a computer and telephone' is simply not true." In reality, Dr. Hardin explicitly said that Kirsten could not sit or type sufficiently to return to her former job as a nurse consultant.

In the Court's view, these omissions made Kirsten's case like two other recent decisions in which the plan administrator's determination was found to be arbitrary and capricious. In the first similar case, the Court held that it was arbitrary and capricious for a plan administrator to "ignore" and "dismiss out of hand" evidence in a functional-capacity evaluation that a claimant was not capable of sitting, concluding this was an "absence of reasoning in the record ." And in the second similar case, the Court found it arbitrary and capricious for a plan administrator "simply [to] ignore" a treating physician's medical conclusion and to "dismiss [other] conclusions without explanation."

The Court held that this precedent demonstrated insistence that procedural reasonableness is the cornerstone of the arbitrary-and-capricious inquiry. As such, the arbitrary-and-capricious review turns on whether the plan administrator communicated "specific reasons" for its determination to the claimant, whether the plan administrator afforded the claimant "an opportunity for full and fair review," and "whether there is an absence of reasoning to support the plan administrator's determination."

By ignoring Kirsten's key medical evidence, the Court reasoned, MetLife could hardly be said to have afforded her an opportunity for full and fair review, and its failure to address that evidence in its determination surely constitutes an absence of reasoning.

This case represents another sign that the Courts are willing to hold disability carriers to the proper standard of diligence in evaluating the claimant's medical evidence of disability.

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Alan Olson writes this web-log to provide helpful information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims.

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