Our Client v. Metropolitan Life Insurance Company
United States District Court for the Middle District of Tennessee (2016)
Our client, a successful manager in a large company, was forced to stop working due to psychiatric disabilities. MetLife approved their request for LTD benefits, but two years later, terminated their benefits for reasons we believed were unreasonable. At the time, our client was receiving treatment from two doctors–a clinical psychologist and a physician who is board certified in psychiatry–and both doctors thought our client was too disabled to work anymore. Yet, MetLife rejected their opinions and instead based their denial decision upon opinions from their own doctors who had never evaluated our client in-person.
We challenged MetLife’s decision in the U.S. District Court for the Middle District of Tennessee. The court carefully reviewed MetLife’s decision-making process under the Employee Retirement Income Security Act (ERISA) and concluded that MetLife did not treat our client’s claim fairly.
First, the court acknowledged that the definition of “disability” in MetLife’s policy was “at best confusing and arguably simply in error.” But the court based its decision against MetLife on two other flaws in MetLife’s decision-making process. The court addressed, first, MetLife’s flawed conclusion that our client was no longer sufficiently impaired to receive LTD benefits, and second, MetLife’s flawed assertion that our client’s care was insufficient to warrant continuing benefits under their policy.
Regarding impairment, we pointed out that MetLife’s physicians did not evaluate our client in-person, which harmed their ability to give an accurate assessment of their impairments. This, we argued, helped demonstrate that MetLife unreasonably credited their opinions over our client’s doctors. The court agreed with us, noting that for psychiatric disabilities like our client’s, it can be particularly important to conduct in-person examinations before rejecting the conclusions of an individual’s treating physicians.
When further assessing MetLife’s decision-making process on impairment, the court criticized MetLife for failing to comply with the ERISA requirement of clearly expressing reasons for terminating benefits in denial letters. ERISA section 1133 requires insurance companies to write denials “in a manner calculated to be understood by the participant.” 29 U.S.C.A. § 1133. MetLife’s denial letter fell short of this standard, according to the court, in a number of ways.
First, MetLife simply concluded, without explanation, that our client’s symptoms were due “to their character rather than their underlying bipolar disorder,” which was unreasonable given the opposing explanations from our client’s treating physicians. Both of MetLife’s physicians failed to explain why they disregarded our client’s doctors’ opinions. Second, neither MetLife physician “addressed the full array of potentially disabling symptoms identified by” our client’s doctors, which made their conclusions appear to be based on a selective reading of the evidence. These two deficiencies coupled with the absence of in-person evaluations led the court to agree with us that MetLife arbitrarily and capriciously relied on lack of impairment to terminate our client’s benefits.
Next, like with impairment, the court explained that MetLife’s “insufficient care” explanation was an unfair basis for terminating our client’s benefits. Our client’s policy with MetLife required their treatment to meet national medical guidelines in order to continue receiving benefits, and our client’s doctors were providing that level of care. Yet, MetLife doctors, according to the court, did not “cite[] any relevant authoritative guidelines in support of their largely conclusory opinions on adequacy of care.” This failure on the part of MetLife’s doctors, as with their opinions on impairment, were made worse by the facts that neither doctor evaluated our client in-person and MetLife’s denial letter did not comply with basic ERISA requirements.
On the latter point, the court specifically faulted MetLife for basing its final denial letter on reasons it failed to sufficiently articulate in its initial denial letter. This failure unfairly deprived our client of the ability to fully explain, with the help of their doctors, that their treatment was sufficient, when viewed as a whole and when considering the different functions each of their doctors served.
For these reasons, the court ordered MetLife to reconsider its denial, using a fair decision-making process that complies with the legal requirements under ERISA. Shortly after this successful court order, we requested that MetLife pay our fees for the work we did as a result of its unfair treatment of our client. MetLife tried to argue that it should not be forced to compensate us for this work, but after considering multiple factors impacting payment of attorney’s fees, the court granted our request, ordering MetLife to pay us $42,186.50.
The court first rejected MetLife’s attempt to argue that it should not have to pay since it never engaged in bad faith, explaining that there was no requirement that MetLife have acted in bad faith. MetLife was still culpable for its flawed decision-making process, concluded the court, even if it did not act in bad faith. In addition to this point, the court found in our favor because it believed that requiring MetLife to pay would deter it and other insurance companies from making the same errors in the future and discourage the lack of thoroughness that MetLife displayed in its decision-making process. For those reasons, the court instructed MetLife to pay us.
