MetLife abused its discretion when it terminated long-term disability benefits

When Judge Stephen V. Wilson delivered his decision on January 13, 2010, it probably resulted in some mixed feelings for Kelly Lavino. She had hoped for a clear victory in her battle with Metropolitan Life Insurance Company (MetLife) to have her long-term disability benefits restored. Instead the judge rendered a decision that may put her at the insurance company’s mercy once again.

Lavino had been a project engineer for Malcolm Pitnie, Inc. One of the benefits of employment included coverage under a short-term and long-term disability plan issued by MetLife. This entitled Lavino, if she became and remained disabled, to long-term disability benefits.

MetLife approves initially for short-term disability, but denies long-term disability benefits

When she became disabled, MetLife initially approved her for short-term disability. But when she applied for long-term disability, her claim was denied. We’ve already discussed the history behind this denial in MetLife terminates long-term disability benefits to woman with fibromyalagia. Now we will look at how the court evaluated this history to reach its decision.

Because Lavino’s long-term disability plan was governed by the Employee Retirement Income Security Act (ERISA), the Court’s first order of business was to decide what standard of review should apply to MetLife’s decision to terminate Latinos benefits.

Because the plan unambiguously gave MetLife discretion in determining whether Lavino was eligible for benefits, the court applied the standard of review known as “abuse of discretion.” In addition to this, the Court found that the administrator had a conflict of interest because not only did MetLife interpret the terms of the plan, but they also paid out benefits. This meant that the Court would have to undertake a thorough examination of the administrative record.

Bias colors long-term disability benefits denial

One of the first things that Lavino pointed out was that NMR was a medical review firm retained consistently by MetLife, with payments reaching $2,780,795 in 2006. Lavino argued that this amount of income could easily bias a physician toward the denial of a claim. MetLife could not produce evidence that they had taken any steps to prevent a conflict of interest such as penalizing inaccurate decisions. The court determined that they would take NMR’s relationship with MetLife into account during the review process.

MetLife fails to provide clear guidelines

Lavino pointed out that MetLife had failed to provide clear guidelines as to what information they needed. And they also consistently miscategorized her job so that the reviewers used the wrong standard to evaluate whether she was disabled. The court found that this was substantiated. MetLife had repeatedly asked for evidence, but never specified what evidence would be appropriate. Her initial claim had been approved based on Dr. Flaningam’s office notes and diagnosis. And at MetLife’s request, he continued faxing progress reports each month. Despite repeated requests for guidance on what type of information MetLife wanted, MetLife never provided a description of what they were looking for in order to perfect her claim.

MetLife uses multiple job classifications for one job

Lavino also pointed out that MetLife did not have a consistent classification for her job. At first it was classified as “medium,” then as “light,” and then as “sedentary.” This inconsistency had a clear impact on how her limitations were reviewed, even though Dr. Payne indicated that he didn’t think she had any impairment, Dr. Lumpkin may have reached a different conclusion if she had known that Lavino’s occupation was not categorized as sedentary, but light.

MetLife asks for evidence of disability that cannot be provided

When the court considered MetLife’s actual decision to deny Lavino’s long-term disability claim, the court found that MetLife had abused its discretion. The Court recognized that “disabling pain cannot always be measured objectively,” and looked to a number of lower court decisions that had reached this conclusion. MetLife’s request for objective evidence was particularly problematic, because it is generally recognized that fibromyalgia and fatigue resist objective verification. The court found that MetLife had established a threshold that could never be met by claimants suffering from fibromyalgia. It wouldn’t matter how disabling their pain was.

MetLife never disputed that Lavino had fibromyalgia. But they denied her long-term disability claim because they said her pain did not limit her from engaging in sedentary employment. Dr. Lumpkin noted that Lavino was not taking Lyrica, the known treatment for fibromyalgia, but did not consider the fact that she had reacted negatively to the medication, as observed by Dr. Flaningam. MetLife argued that by refusing to take Lyrica, Lavino was trying to evade work by pretending she was sick.

MetLife tries to change reason for denying long-term disability claim

MetLife also argued that she had to be able to work because she wasn’t taking the weaker pain medications such as ibuprofen. But the court observed that throughout her medical history, her doctors had experimented with different pain medications and even supplements, all of which did not bring her any relief. Even MetLife’s reviewing doctors observed that she was compliant with her doctors recommended treatment plan. And none of the denial letters had mentioned anything about MetLife having an issue with her reluctance to take medication. Now that the case was in court, MetLife couldn’t change the grounds for their denial. As far as the court was concerned, it looks like MetLife was casting about for an excuse to reject the claim rather than conduct an objective evaluation.

Paper review ineffective for fibromyalgia

The court also found it problematic that MetLife did not order a physician exam instead of limiting its review of her record to a paper review. While in many cases this would not have been determinative, the fact that fibromyalgia is a condition that can only be objectively verified through a physical examination, a physical examination would have demonstrated that MetLife was seeking to make a more objective decision.

When the court considered that MetLife admitted that there is no objective test to measure the functional limitations of someone who suffers from fibromyalgia pain, they found it unreasonable for MetLife to turn down her application for benefits because she couldn’t produce evidence. This was the primary reason her claim was denied.

Court finds six reasons long-term disability denial abuses discretion

So six things added up against MetLife. There was a structural conflict. Lavino’s claim was reviewed as though she had a sedentary position when her job classification was light or medium. MetLife’s doctors only conducted paper reviews. MetLife never told Lavino what objective evidence they required. MetLife admitted that pain cannot be measured objectively. But most importantly in the Court’s eyes, MetLife denied her claim based on the fact that Lavino had not supplied objective evidence. The conclusion: MetLife had abused its discretion when it denied Lavino’s long-term disability claim.

Lavino wanted the court to award her benefits from the date of denial to the present date. But she had been denied based on the description of her own occupation. Retroactive reinstatement of benefits was appropriate, and reinstatement of terminated benefits was likewise appropriate. But MetLife had never had the opportunity to consider Lavino’s application for long-term disability benefits under the “any occupation” standard. This meant that Lavino could not ask for the court to approve an “any occupation” claim.

MetLife has to pay some back disability

Court Orders MetLife to Consider long-term disability application under the “any occupation” standard.

The Court’s final settlement of the matter was to order that MetLife pay Lavino benefits under the “own occupation” standard until the time that those benefits would have expired. The Court sends the decision regarding Lavino’s qualifications for long-term disability coverage under the “any occupation” standard back to MetLife. MetLife will know have the opportunity to review the claim once again. Unfortunately, if Metlife denies the claim again, Lavino will have to submit an Appeal and then engage in a new lawsuit.