Case Story: Our Client v. Metropolitan Life Insurance Company
Our client, a health physics technician at USEC’s Paducah Gaseous Diffusion Plant, became disabled from depression and anxiety in October 2001. Our client filed for and was granted short term disability benefits. Id. at *2,*3. When their short term benefits expired, our client applied for and was granted long term disability benefits. Id. at *3. After the Social Security Administration deemed our client to be totally disabled and awarded their benefits in 2003, MetLife began reviewing our client’s file to determine their further eligibility for long term benefits. Id. at *3. For the first couple of years, the insurance company looked at whether they could do their own previous job as a health physics technician. Id. at *2. After two years, the definition of disability changed to “any occupation,” meaning they would grant their claim for benefits only when they found their unable to do any job that matched their education, training, and experience. Id. at *3.
In March 2005, MetLife asked our client to provide treatment notes from October 2004 through March 2005, their most current restrictions and limitations and asked to have an enclosed behavioral assessment form completed. Id. at *4. The notes of Dr. Meyer, our client’s treating physician, stated that our client had “no energy” and that they had to “push self to get out of bed.” Id. at *4. Dr. Meyer also stated that our client would be a “fatigued, inattentive employee prone to absenteeism and accidents.” Id. at *4. MetLife called Dr. Meyer to confirm this, then approved our client’s long term disability benefits until August 31, 2005. Id. at *4.
On October 4, 2005, MetLife notified our client that it was terminating their benefits effective August 31, 2005. Id. at *5. The denial letter stated that Dr. Meyer had not provided objective findings that indicate[d] an inability to function, no mental status exam, and no global assessment of functioning score. Id. at *5. However, according to the Plan, the burden was not on our client to provide any information that was not requested, and MetLife had not requested that information. Id. at *5.
Our client appealed the denial of their disability benefits and included a letter written by Dr. Meyer on October 15, 2005, in support of their appeal. Id. at *5. He stated our client had tried every medication, alone and in combination, that he had recommended, but that they remained seriously depressed and functionally impaired. Id. at *5. Dr. Meyer emphasized that they were not a patient who exaggerated their symptoms and that they preferred social isolation, even at times to the exclusion of their own children. Id. at *5.
The court determined that MetLife’s initial denial of their benefits on October 4, 2005, was not based on an appropriate review of their file. Id. at *7. MetLife “faulted our client and Dr. Meyer for not providing information that it did not seek.” Id. at *8. “There [was] no burden on our client to proactively prove their disability on a continuing basis.” Id. at *8. MetLife arbitrarily and capriciously relied on a supposed lack of information to revoke our client’s disability benefits. Id. at *8.
MetLife hired Dr. Kessler, a board-certified psychiatrist, for a file-only review. Id. at *5. Dr. Kessler said our client had received minimal and incomplete treatment. Id. at *6. The court said there was no reasoned, rational basis for crediting Dr. Kessler over Dr. Meyer and to do so meant that MetLife was acting arbitrarily and capriciously. Id. at *11 (referencing Kalish v. Liberty Mutual, 419 F.3d 501, 510 (6th Cir. 2005) (discrediting non-examining physician who failed to rebut treating physician’s diagnosis and conclusions)); Elliott v. Metropolitan Life Ins. Co., 473 F.3d 613, 620 (6th Cir.2006) (“that MetLife gave ‘greater weight’ to a non-treating physician’s opinion for no apparent reason lends force to the conclusion that MetLife acted arbitrarily and capriciously.”). “Failure to conduct a physical examination — especially where the right to do so is specifically reserved in the plan — may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination.” Our client v. Metro. Life Ins. Co., 2007 WL 2746886 at *12 (citing Calvert v. Firstar Fin., Inc., 409 F.3d 286, 295-96 (6th Cir. 2005)).
MetLife also apparently disregarded the Social Security Administration’s (SSA) determination that our client was completely disabled. Under the terms of the Plan, a beneficiary was required to apply for SSA benefits, and, if benefits were awarded, the amount paid out by the plan was reduced by the amount received from the SSA. Id.
MetLife prompted our client to apply for SSA benefits and even referred them to an attorney to assist her. MetLife offset its payment to our client in the amount of their SSA award from 2002 until it revoked their benefits in 2005. There was nothing in the record showing that our client’s SSA benefits [had] been revoked. MetLife therefore benefitted from our client’s SSA disability determination for four years before declaring them not to be disabled and revoking their disability award.
The court concluded that MetLife’s denial of our client’s benefits was arbitrary and capricious and sent the case back to MetLife for a full and fair review of our client’s disability claim. Id. at *16.
