Case Story: Our Client v. Metropolitan Life Insurance Company

Insurance company is wrong to rely on file-reviewing doctors who ignored evidence and to fail to have claimant examined when the court suggested it. Evaluation of disability caused by mental health issues.

After the court in the Eastern District of Tennessee found that MetLife’s original decision to deny our client benefits was arbitrary and capricious, but gave MetLife a second chance to make the decision properly. The court was not willing to allow MetLife to continue to deny the claim when MetLife did not follow the court’s suggestions.

The Court cannot accept Defendants’ argument that it conducted a reasonable review of Plaintiff’s claim on remand. Defendants disregarded the Court’s prior Order, which strongly suggested that Defendants obtain an IME [Independent Medical Exam], and relied solely on file-reviewing physicians. Defendants then accepted the consulting physicians’ opinions that Plaintiff was not disabled, . . .a conclusion which was unreasonably reached by virtue of placing great weight on one statement in the medical record, to the exclusion of a significant amount of other evidence that was not adequately considered.

MetLife also relied heavily on the statement of one doctor who stated in one note that our client “likely could do some type of work.”  The court disagreed with MetLife that it was reasonable to interpret this as a definitive statement that our client “could perform some kind of work.” Instead, the court agreed that “this statement raised questions about [our client’s] abilities, but did not resolve them, and that the statement was insufficient to support Defendants’ decision.” Id., 803 F. Supp. 2d 803, 812. When read in context, and with the other evidence, MetLife was “plain wrong” to rely on this isolated statement.  Id. MetLife’s

reliance on one statement offering the vague idea that [our client] might be able to work is unreasonable . . . the Plan language does not give [MetLife] license to determine that Plaintiff is ineligible for benefits on the basis of one statement, without a thorough review of the medical record—particularly when this statement, . . .does not provide any definitive answers (or a definite conclusion that Plaintiff is not disabled) and instead only raises questions.

The court also agreed with the Magistrate Judge that is was improper for MetLife to rely only on paper file reviews while also criticizing our client’s evidence because their doctors did not conduct certain tests that MetLife’s doctors suggested should have been done.  Id, at 813.  Because MetLife did not tell our client, or us, about what tests they would have liked to have seen until MetLife’s denial letter.  The Court explained:

In essence, [MetLife was] requiring that [our client] substantiate their disability by means not outlined or requested in any documentation until their benefits had already been denied. The Court, therefore, concludes that [MetLife] failed to undertake a full and fair review of [our client]’s claim on remand and again concludes that the decision to deny benefits on remand was arbitrary and capricious.

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