Case Story: Our Client v. Metropolitan Life Insurance Company

United States District Court for the Eastern District of Tennessee (2009)

Our client, an employee for a large home improvement retailer, suffered from several medical conditions, including radiculopathy in the spine. Metropolitan Life Insurance Company (MetLife) initially granted her claim for long-term disability (LTD) benefits, but terminated them after 24 months. MetLife claimed that she was able to return to work and therefore was no longer entitled to LTD benefits.

We brought suit on behalf of our client against MetLife for reinstatement of LTD benefits that our client was entitled to. We argued that MetLife was unreasonable in determining that our client was not disabled under her LTD plan. MetLife argued that the record lacked objective medical evidence of post-operative radiculopathy as required under her plan that would deem her disabled. The court ruled in our favor and remanded our client’s claim back to MetLife for a full and fair review of her claim.

In reaching this conclusion, the court had to determine whether MetLife was arbitrary and capricious in its determination that our client was not disabled. In other words, the court was not determining whether MetLife’s decision was right or wrong, but rather whether it was unreasonable in its determination. There were several reasons that suggested MetLife was unreasonable in its determination to terminate our client’s benefits.

The court summarized the relevant portion of our client’s LTD plan at issue in her case:

The plan also limits LTD benefits to 24 months if the claimant is disabled due to: “A soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surroundings soft tissue; including sprains and strains of joints and adjacent muscles, unless the disability has objective evidence of … Radiculopathies.” The Plan defines “Radiculopathies” as a disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.

(emphasis added) There were two tests that indicated our client suffered from radiculopathy as stated in her LTD plan. The first was a CT scan that showed degenerative disc disease and a possibility that her right S1nerve root may be compromised. The second test was an electromyogram (EMG) study which suggested either an old nerve root injury or an ongoing nerve root compression. If it were the latter, that would suggest she was disabled and not able to continue working.

In reviewing our client’s claim, MetLife retained a doctor of osteopathic medicine to make a determination as to whether she was disabled. However, these two critical tests were not accounted for when concluding to terminate our client’s benefits. The reviewing doctor said that our client had “mostly subjective pain complaints without significant positive objective findings to account for the pain issues.” MetLife used this information to conclude that our client was not disabled and could continue to work, despite a letter from her treating physician stating she had “clearly documented nerve compression of the lumbar spine with radiculopathy,” and that the “reviewing physician [for MetLife] clearly missed it.”

The court held that MetLife was unreasonable because it decided to handpick evidence that supported terminating benefits, while also ignoring evidence that supported the continuation of benefits. The court noted that treating physicians are not necessarily entitled to special deference, but their opinions cannot be arbitrarily ignored either. In our client’s case, because the reviewing physician did not account for the most recent tests that supported her claim for disability, MetLife was arbitrary and capricious in denying benefits.

The court remanded the cases back to MetLife for a full and fair review of our client’s claim. The court did not award an outright grant of benefits to our client, because it did not want to make determinations that should be left to medical specialists. However, the court did award partial attorney’s fees to our client for the successful claim.

In determining whether to award attorney’s fees in ERISA cases, the court considers five factors: the degree of the opposing party’s culpability or bad faith; the opposing party’s ability to satisfy an award of attorney’s fees; the deterrent effect of an award on other persons under similar circumstances; whether the party requesting fees sought to confer a common benefit on all participants and beneficiaries of an ERISA plan or resolve significant legal questions regarding ERISA; and the relative merits of the party’s’ position. The court ruled that the first, second, third, and fifth factors weighed in favor of our client, and therefore partially granted our motion for attorney’s fees for the successful claim regarding our client’s radiculopathy.

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