Legal Summary: Platt v. Walgreen Income Protection Plan for Store Managers (& MetLife)

455 F.Supp.2d 734, 736 (M.D. Tenn. 2006)

Our client applied for LTD benefits from MetLife when she became so sick she could not continue working.  MetLife originally approved her claim and paid benefits for about two years before denying the benefits.  After MetLife denied her claim, our client appealed on her own and was denied again by MetLife.  She hired us and we submitted additional information to MetLife.  MetLife refused to consider the additional information saying that our client had used her one chance to appeal, so we sued MetLife. Platt v. Walgreen Income Protection Plan for Store Managers, 455 F.Supp.2d 734, 735-743 (M.D. Tenn. 2006).

Because her employer provided the LTD insurance, our client’s case fell under the federal ERISA law.  ERISA usually makes cases harder for employees; one of the reasons is that under ERISA, insurance companies write their policies to include language saying they have “discretion” to deny benefits. Insurance companies are allowed to do that in many ERISA cases.  If that language applies, a court gives deference to the insurance company under an “arbitrary and capricious” standard of review.   Under those rules, the insurance company wins so long as they are reasonable, even if they might be wrong. Id. at 743.

MetLife had discretionary language in its policy that covered our client; however, despite that very difficult standard of review, with our help, the court overturned MetLife’s decision to deny benefits.

One of the first issues for the court was that our client appealed on her own before hiring us.  MetLife denied her and said her appeals were over before we could help.  We attempted to submit a lot more information that documented our client’s disability.  The court held that it could not consider the additional information we submitted, because under the rules courts follow in ERISA cases, the court only considers the information submitted to MetLife or that MetLife obtained during the appeal process.  Because the new information was not submitted until after MetLife had denied the appeal, and MetLife refused to consider the late information, the information was “technically not part of the administrative record before the Court.” Id, at 742.

One argument we made was that because our client appealed on her own early during the 180 day appeal period, was denied quickly, that by the time she hired us, and we submitted the new information, it was still submitted to MetLife within the original 180 days. Even though we submitted all the new, good information before the 180 would have been up, because MetLife refused to consider it, the court help that this new information was not “in the record” and would not consider it. Id., at 743. [This is an important lesson to learn.  People should hire an attorney before they appeal on their own.  People should be very careful not to use up their only chance to appeal and to appeal with the help of an experienced ERISA attorney.]

In regards to the evidence in the record, MetLife argued that the evidence did not provide sufficient “objective findings” to show her impairment caused her to have disabling limitations.  Id., at 744.  MetLife relied on Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376 (6th Cir.1996) and Bucks v. Reliance Standard Life Ins. Co., 215 F.3d 1325, 2000 WL 659029 (6th Cir.2000) (unpublished) to support its argument that MetLife could deny a claim for a lack of “objective evidence.” Platt, 455 F. Supp. 2d at 744.  The court, in this case, explained that, in both cases, the Sixth Circuit observed that some objective evidence of disability is necessary because “subjective complaints are easy to make but almost impossible to refute.” Yeager, 88 F.3d at 382; Bucks, 2000 WL 659029 at *4. But, in Yeager, no doctor even provided a diagnosis for the claimant in that case, while here, in this case, two treating doctors opined that the claimant met the clinical diagnostic criteria for her condition. Platt, 455 F. Supp. 2d at 744.  Similarly, in Bucks, the claimant suffered mental disability and had worked with it for years, which is a different situation from the claimant in this case. Platt, 455 F. Supp. 2d at 744.

Since MetLife’s decision could not be affirmed based on MetLife’s argument that there was not enough objective evidence, the court explained that the case turned on MetLife’s decision to follow its own doctors over that of the claimant’s doctors who supported disability.  The court clarified that, in reviewing whether MetLife properly considered those opinions, “the Court must keep in mind MetLife’ s conflict of interest in its roles as both Claim Administrator and benefit provider, as well as the conflict of interest of MetLife’s consulting physicians, whom MetLife retained and paid to review Plaintiff’s file.” Platt, 455 F. Supp. 2d at 744.  The Court relied on Calvert v. Firstar Finance, Inc., 409 F.3d 286, 292 (6th Cir.2005), which the court explained noted that a “claims administrator [i.e., an insurance company deciding LTD claims] ha[s] clear incentive to contract with individuals who were inclined to find in its favor that claimant was not entitled to long-term disability benefits, especially because claimant was young and paying long-term benefits would be expensive.”

In reviewing how an insurance company should weigh conflicting medical opinions, the court, in this case, analyzed the Supreme Court’s decision in Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825 (2003).  In that case, (another case where MetLife denied benefits,) the Supreme Court held that the insurance company is “not obliged to accord special deference to the opinions of treating physicians,” nor, under ERISA’s rules, is there “a heightened burden of explanation on administrators when they reject a treating physician’s opinion.” Platt, 455 F. Supp. 2d at 744-5, citing to and quoting from Black & Decker, 538 U.S. at 831, 123 S.Ct. 1965. The court, in this case, went on to explain that “the Supreme Court made clear, however, that [insurance companies in this position] may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Platt, 455 F. Supp. 2d at 745, citing to   Black & Decker, 538 U.S. at 834 and Smith v. Continental Cas. Co., 450 F.3d 253, 262 (6th Cir.2006). And, further, the court, in this case, explained that the “consulting physicians hired by” MetLife, who only reviewed the file, “may not make credibility determinations concerning the claimant’s subjective complaints without the benefit of a physical examination.”  Platt, 455 F. Supp. 2d at 745, citing Smith, 450 F.3d at 263.  Therefore, “under Nord, MetLife was not required to give deference to [the treating doctor’s] opinion over the opinions of its own consulting physicians. But MetLife’s consultants were not free to discredit Plaintiff’s subjective complaints of pain or its impact on her physical capacity without a physical examination.”  Platt, 455 F. Supp. 2d at 745, citing, Smith, 450 F.3d at 262–263.

The court later explained, simply relying on file reviews alone, without any other factor, is not improper, “the 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.” Platt, 455 F. Supp. 2d at 746, quoting from Calvert, 409 F.3d at 295.

MetLife also argued that they could deny the claim because the claimant’s doctors “did not conduct any functional, neuropsychological or other testing to document a deterioration in her functional capacity,” as was suggested by one of MetLife’s doctors.  Id., at 746. However, the court pointed out that it was Metlife’s doctor who recommended the testing and, from the report, that the doctor thought Metlife should do the testing.  Id.  The court concluded that because MetLife failed to obtain its own “independent medical examination and/or functional capacity evaluation, when its own consulting physician suggested such an approach, supports the conclusion that MetLife’s decision to deny benefits was arbitrary and capricious, particularly when MetLife’ s conflict of interest is taken into account.” Id., at 746–47.

The court ultimately agreed with us and concluded that MetLife had acted arbitrarily and capriciously in denying the claim.  MetLife should not have rejected our client’s complaints simply because she made subjective complaints, should not have simply relied on their own doctors without properly considering the treating doctors, and should not have relied on their doctors opinion as to the claimants credibility, especially when the policy allowed the claimant to be examined by a doctor of their choice.  While the court said MetLife’s decision was wrong, the court did not award benefits but remanded to MetLife to reconsider and to consider the evidence it did not look at before.