Legal Summary: Smith v. Babcock and Wilcox Technical Services, LLC

Smith v. Babcock and Wilcox Technical Services, LLC
No. 3:15-CV-255, 2016 WL 3355343 (E.D. Tenn. 2016)

Our client worked as a project manager for Babcock & Wilcox Technical Services, LLC until he became disabled due to lymphocytic leukemia. He applied for long-term disability benefits with MetLife—the administrator of the Babcock & Wilcox Plan–citing three causes of his long-term disability: (1) fatigue resulting from his chronic lymphocytic leukemia, (2) chronic gastritis, and (3) high stress levels, which he attributed to “mentally processing” his cancer.

His primary care physician submitted a physician’s statement to MetLife on his behalf, writing that our client was “not physically able to work,” citing “severe chest pain, fatigue, [and] anxiety” in his conclusion.

MetLife denied his claim, writing that he did not satisfy its definition of “totally disabled.” To be “totally disabled” under the Babcock and Wilcox plan you (1) must be unable to perform the duties of your regular job with the company due to illness or injury and (2) must be under the regular care of a licensed practicing physician. Our client appealed.

MetLife retained an Independent Physician Consultant to review our client’s appeal. During the appeal, he continued to have the same symptoms, met with his physicians, and underwent additional medical testing—information regarding all of which he submitted to MetLife for its consultant’s review. MetLife’s consultant wrote that our client was not disabled because neither his chronic lymphocytic lymphoma nor any other physical condition was responsible for his “symptomatic complaints.”

MetLife’s physician spoke with our client’s primary care physician, who informed him of our client’s “significant amount of anxiety,” which was a “major factor in explaining his symptoms,” including gastrointestinal symptoms. MetLife’s physician, once again, wrote that our client was not totally disabled, but conceded that he is “not qualified to assess whether [our client’s anxiety] results in any restriction or limitation as that is outside the purview of [his] specialty.”

Multiple physicians echoed our client’s primary care physician’s opinion, writing to MetLife that the stress caused by “[our client’s] chronic leukemia” is “factual” and worsens his gastrointestinal symptoms while also claiming that he “appears to be anxious,” and has “multiple somatic complaints without obvious physiologic basis.”

After reviewing this new information, MetLife’s physician still opined that our client was not totally disabled due to chronic lymphocytic leukemia. However, he failed to mention our client’s anxiety. Our client’s physician wrote to MetLife again, emphasizing that chronic lymphocytic leukemia is not the reason for his claim and is “merely a stressor to [his] severe Gastro-Intestinal issues,” noting that he has “extreme anxiety.”

MetLife’s consultant wrote a third report, stating that our client’s gastrointestinal symptoms are “largely psychiatric” and could be the basis for functional limitation, but that a psychiatric assessment was “beyond the scope of this review,” concluding that the medical information provided failed to support “any functional impairment.”

Based on the opinion of their hired doctor, MetLife continued to deny our client’s claim.

We brought suit, asserting that MetLife’s review of our client’s claim was arbitrary and capricious because it was a file-only review (ie., that MetLife had not had any doctor examine our client) and MetLife failed to provide a full and fair review of their file-reviewing doctor’s report.

The court applied the arbitrary and capricious standard to its review of MetLife’s denial of our client’s claim. An administrator’s decision is not considered arbitrary and capricious if it is the result of a “deliberate, principled reasoning process,” and if it is supported by substantial evidence, meaning “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”  McDonald v. W.-S. Life Ins. Co., 347 F.3d 161, 171 (6th Cir. 2003); see Davis v. Ky. Fin. Cos. Ret. Plan, 887 F.2d 689, 693 (6th Cir. 1989.)”

Under ERISA, courts are obligated to ensure that an administrator conducted a “full and fair” review of a claim denial. Glenn, 554 U.S. at 117.

We argued that our client’s medical records and other medical opinions in the record established that “he was unable to work … on the grounds of stress and anxiety provoked gastrointestinal symptoms.” We also argued that by relying on their own hired physician, who lacks training or experience in the medical field relevant to his claim, MetLife “failed to meaningfully grapple with [his] stated reason for being disabled.”

If an administrator chooses not to conduct a physical examination and simply rely on a file-only review, the court will consider this as a factor when determining if it acted in an arbitrary and capricious manner.  When an independent physician “flatly contradict[s] the conclusions of those who examined” a beneficiary, the administrator’s decision to perform a file-only review is more likely to be improper. Morris v. Am. Elec. Power Long-Term Disability Plan, 399 Fed.Appx. 978, 990 (6th Cir. 2010).

The court determined MetLife’s file-only review weighed in favor of a determination that its denial was arbitrary and capricious because MetLife’s physician flatly refuted our client’s physician’s conclusions and downplayed our client’s symptoms by making an adverse “credibility determination.” When an independent physician “flatly contradict[s] the conclusions of those who examined” a beneficiary, the administrator’s decision to perform a file-only review is more likely to be improper. Morris v. Am. Elec. Power Long-Term Disability Plan, 399 Fed.Appx. 978, 990 (6th Cir. 2010).

MetLife’s reliance on its physician’s adverse credibility determination is an indication that MetLife placed “greater weight” on the file-only review than on the opinions of the physicians who physically examined our client. This is another factor indicating that MetLife acted arbitrarily and capriciously when reviewing our client’s file.

The court found that MetLife’s physician’s statement, that our client suffers from “only chronic gastritis,” is an adverse credibility determination, which discounts the evidence in the record that casts his physical symptoms as severe. MetLife’s reliance on this adverse credibility determination was “troublesome” because none of our client’s three physicians voiced their misgivings as to the severity of his physical symptoms. The record also showed objective advice that our client had experienced severe weight loss as his symptoms were impacting his well-being. Repeatedly, MetLife’s physician discounted our client’s physician’s opinions without providing a sufficient explanation for doing so.

When a court reviews a plan administrator’s decision-making, it must review the “quality and quantity” of the medical evidence and the opinions on both sides of the issues. DeLisle, 558 F.3d at 446 (quoting McDonald, 347 F.3d at 172). An administrator may not reject a treating physician’s opinion without “giv[ing] reasons for adopting an alternative opinion.” Elliott, 473 F.3d at 620. The court determined that MetLife did not offer an explanation consistent with the quantity and quality of the medical evidence but performed a selective review of the record, through which it ignored evidence that favored our client’s claim.

By failing to call upon a qualified professional to review our client’s medical records and evaluate his mental health, MetLife committed “a serious procedural irregularity,” compromising his right to a full and fair review. Morgan v. UNUM Life Ins. Co. of Am., 346 F.3d 1173, 1177 (8th Cir. 2003.) MetLife also unfairly used our client’s recent use of anti-anxiety medication as reasoning in its denial, ignoring the fact that he had been on other anti-anxiety medications prior.

The court concluded that MetLife engaged in a haphazard and selective review of the record, downplaying or outright ignoring evidence that was favorable to our client’s claim.

The court determined that MetLife’s review was not characteristic of a deliberate, principled reasoning process. In particular, by conducting a file-only review when a physical examination was necessary and by failing to consider much of the medical evidence, MetLife lacked substantial evidence for its decision. The court ruled that MetLife’s denial of our client’s long-term benefits was arbitrary and capricious, and remanded the case to MetLife, requiring MetLife to conduct a full and fair review consistent with the court’s opinion.