Negative Statements by Claimant’s Doctor Show He’s Unbiased

This long-term disability benefits case was a clean victory for our client “Kim”, a native of Hawaii. Kim was a Reservation Tickets Sales Representative for United Air Lines. United purchased disability coverage for its employees through MetLife.

In 2000, Kim fell while transporting passengers from the air terminal to the baggage claim area, injuring her neck and lower back. Kim continued to have problems with her neck and back and then reinjured her back in 2005. MetLife determined that Kim was disabled and entitled to benefits for more than 2 years but then terminated her long-term disability benefits. In its letter terminating benefits, MetLife gave two reasons for the decision: (1) Kim’s medical records indicate that she is capable of performing work at a sedentary level and therefore she does not meet the definition of disabled under the Plan; and (2) Kim has not been aggressive in her treatment protocols.

The Court found that in its denial of Kim’s appeal, MetLife effectively did a “copy-paste job” on Dr. Smith’s report, failed to weigh the evidence for and against a finding of disability, and therefore was arbitrary and capricious in terminating her benefits. Ultimately, MetLife rejected Kim’s appeal because of the lack of “clinical evidence” to support a finding of disability. The Court disagreed because first, the medical record did contain some “objective evidence” in the form of an MRI. There was also a mention in Dr. McCaffrey’s reports about awaiting results from a new MRI. In addition, Dr. Seberg found that, whether physically healed or not, Kim’s range of movement and attendant pain may have deteriorated to the point that “she is going to be incapacitated for the rest of her life.” Second, a claimant is not required to substantiate her subjective accounts of pain with objective evidence, under disability law precedent. Third, while Kim’s experience of pain was necessarily subjective, how much it limited her functional capabilities could be objectively measured.

The Court rejected MetLife’s argument that Kim’s doctor was critical of her rehabilitation efforts. To the contrary, the doctor’s willingness to be critical of Kim’s efforts suggested his findings as to the extent of her pain and disability were not slanted by some bias as her treating physician. By contrast, MetLife’s selective reliance on Dr. Seberg’s assessments of Kim — relying extensively on his critical assessment of her treatment protocol at times, but effectively ignoring his clinical findings as to the extent of her pain, physical limitations, and ultimate conclusion that she was unable to work — called into question its own bias in terminating Kim’s benefits.

MetLife claimed that Kim’s late efforts at rehabilitation were simply her getting in line once her LTD benefits were imperiled. Rejecting this argument, the Court found that if MetLife terminated Kim’s benefits because of her failure to engage in adequate medical treatment, then MetLife needed to explain why her physical therapy efforts and adherence to a pain medication protocol were not at least worth consideration at the time of her appeal.

MetLife also failed to consider the SSA’s determination that Kim was “unable to perform any past relevant work,” and that “there are no jobs that exist in significant numbers in the national economy that the claimant can perform.” The SSA’s determination was not mentioned in MetLife’s initial termination letter, nor in its letters rejecting Kim’s appeals, all of which post-dated the SSA’s determination. MetLife was required to at least consider the SSA’s determination in deciding whether Kim’s LTD benefits should remain in place, particularly where the SSA determination was made a mere three months before MetLife’s termination of benefits, the Court held.

We remain hopeful that this decision against MetLife will send the same message to other long-term disability carriers in Hawaii and nationally, that their careless treatment of benefit claims by genuinely disabled people will not be tolerated by the courts.

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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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