Filed October 20, 2009
Opinion by Judge J. Frederick Motz
Held: Summary judgment granted to defendant insurance company, MetLife, because it did not abuse its discretion under ERISA in terminating plaintiff's long term disability ("LTD") benefits based on the reports of independent consultant physicians who reviewed plaintiff's medical records and did not do their own vocational review or actual physical examination of the plaintiff.
Facts: In March 2007, the plaintiff submitted a claim for LTD benefits under his employer's LTD plan, governed by ERISA, after experiencing a tremor in his arm while driving. MetLife (the Plan's claim administrator) approved the claim after evaluating plaintiff's medical records from his physician and neurologists. MetLife determined that plaintiff met the Plan's definition of "disabled" and informed the plaintiff that he had a continuing obligation to provide proof of his disability as defined by the Plan to continue receiving benefits.
In October 2007, MetLife referred plaintiff's claim file, including his medical records, to an independent physician consultant. The consultant expressed the opinion that the medical records did not manifest incapacity to the extent of being disabled. Accordingly, MetLife decided to terminate the plaintiff's LTD benefits.
Plaintiff submitted an appeal that included additional medical documentation and other materials in support of his claim. MetLife referred the claim to two additional independent physician consultants who concluded that the plaintiff was not unable to perform to his job and his mental status results were essentially normal. MetLife submitted the consultant reports to plaintiff's treating physicians for review and comment. Only one physician responded, stating that the plaintiff was physically incapacitated by his disorder and emotionally disabled. Finding this response incomplete and failing to provide objective evidence in support of disagreement with the independent consultants, MetLife issued a letter upholding its decision to terminate the plaintiff's benefits. Plaintiff filed suit thereafter.
Analysis: The parties agreed that the Court could only find in favor of the plaintiff if MetLife abused its discretion in terminating the plaintiff's LTD benefits. The Court held that MetLife did not abuse its discretion because it conducted a full and fair review of the claim.
MetLife collected numerous medical records from the plaintiff's various health professionals and therefore, according to the Court, MetLife's decision resulted from a "principled decision-making process." In addition to reviewing the plaintiff's medical records from its physicians, MetLife also requested reviews from three independent consultants and requested responses from the plaintiff's doctors. The Court noted that the fact that MetLife initially awarded LTD benefits to the plaintiff did not weigh in favor of the plaintiff's position because MetLife was entitled to continue to evaluate the plaintiff's condition even after initially awarding benefits.
The Court also ruled that it was not an abuse of discretion for MetLife to rely more heavily on the consultants' determinations than those of the plaintiff's doctor since an administrator, such as MetLife, can adopt the position of one doctor over another.
Finally, the Court held MetLife's decision not to secure an additional vocational assessment to the plaintiff's vocational assessment was not an abuse of discretion because the Fourth Circuit does not require a vocational assessment in the course of a full and fair review. Moreover, MetLife had nevertheless reviewed the report submitted by the plaintiff's vocational consultant.
The full opinion is available in PDF.