Court reverses MetLife's denial of long term disability benefits for graphic designer suffering with fibromyalgia

A sedentary position is no guarantee that an employee will not need to take advantage of the disability insurance plan offered by his or her employer, as the story of Bud Minton demonstrates. He worked as a graphics designer for Deloitte and Touche. The job involved long hours at the computer, which after nine years began to take its toll. The pain in his arms, upper back and neck became so severe that he took a 10-month leave of absence in 2001 and 2002.

The physical therapy he underwent during the 10-month leave enabled him to return to work in July 2002. He was careful to spend less time at the computer. Then four years later, Deloitte and Touche changed his job duties. This resulted in increased time at the computer and his pain worsened. When only a month later his employer gave him an ultimatum – either accept a severance package or move into the position of graphics coordinator – he asked for time off to recover.

Minton stopped working the next day. In December, 2006 he submitted a claim to the Metropolitan Life Insurance Company (MetLife), the disability insurance company that served as the Deloitte and Touche USA LLP Plan (Plan) claims administrator and funded the benefits paid to employees under the Plan. He submitted a statement from his attending physician which stated that he had been diagnosed with fibromyalgia, the chronic soft tissue condition marked by pain, and frequently accompanied, especially in its early stages, by depression. His doctor expressed the opinion that Minton could sit, stand and walk for up to eight hours per day, but he was not able to work for more than two hours at a time at the computer.

Minton received phone notice on February 7, 2007 that his claim was going to be denied. The MetLife representative agreed to give him time to submit additional medical records from his doctor. He saw the doctor on February 13, and the doctor sent MetLife a one-page note stating that his examination revealed no new objective findings. He stated that he found that Minton’s fibromyalgia seemed to be responding to treatment and gave his recommendation that Minton not return to work until at least May 15, 2007.

MetLife then sent Minton’s file to a board-certified orthopedic surgeon. This physician found that Minton was not “so physically impaired from fibromyalgia that he is unable to do his sedentary job functions which require(s) computer/phone work.” He supported his opinion that Minton had not been impaired since August 2007 by stating that Minton’s treating physician had failed to document any musculoskeletal abnormality that would cause any functional limitation.” He claimed that the notes indicated that Minton’s treating physician was giving supportive therapies for his patient’s complaints of pain, but without diagnostics to show cause, there was no reason to consider Minton physically impaired.

MetLife denied Minton’s claim on March 12, 2007. They explained in the decision what the orthopedic surgeon had concluded and informed him that “Although office notes indicate your ongoing complaints of pain, there are no clinical or diagnostic findings that substantiate restrictions and limitations or an impairment of such severity that would prevent you from performing your job.”

Minton filed an ERISA Appeal. MetLife sent Minton’s file to a board-certified rheumatologist. This physician spoke with Minton’s doctor. Despite the fact that he found that Minton’s doctor had done an appropriate and extensive workup, he still concluded that there were no objective findings from a rheumatology viewpoint to justify placing restrictions or limitations on Minton’s activities.

MetLife also sent Minton’s file to a psychiatrist to evaluate whether Minton would qualify for a psychiatric disability. The psychiatrist found that Minton’s depression was not disabling, and Minton did not contest this finding.

Minton asked MetLife to send the rheumatologists report to his doctor. The disability company did so. The response was a detailed 11-page report. In it, Minton’s doctor gave a detailed history of Minton’s condition, its progress and the treatment plan. He noted the “decreased range of motion in his upper back and shoulders” and “tautness in his forearm, shoulder, cervical, and upper back muscles.” He acknowledged that the amount of pain Minton claimed to experience would seem out of character with his apparent lack of objective physical impairments, but to the trained physician this was proof that Minton was suffering from chronic soft tissue pain (fibromyalgia). Minton’s doctor made it clear that objective tests such as X-rays were useless as a diagnostic tool for fibromyalgia.

He also discussed the pain treatment strategies he had used. Minton had tried everything from aspirin and vitamin C to Lexapro, Soma, nortiptyline, and Cymbalta. Nothing had helped beyond a “limited extent.” None of the treatments relieved Minton’s pain to the point where he could spend an 8-hour workday at the computer.

This information was soon supplemented with a functional capacity test. The January 16, 2008 test evaluated Minton’s ability to work at a computer. Minton was examined before the testing began. After 50 minutes performing the assigned task, Minton could not continue. His doctor noted increased sensitivity in tender points on his upper back, neck and forearms. Minton’s range of motion had decreased, the muscles in his forearm were stiff, and the muscles in his upper back and shoulders were swollen and his shoulders were sloping. He expressed his opinion that this test proved that Minton experienced changes in his body when he used the computer that proved objectively “that computer use causes functional limitations.”

These reports were sent to the rheumatologist. One the one hand he praised Minton’s doctor for his excellent diagnostic work and treatment plan. Yet, he held to his opinion that there were no objective findings to support Minton’s claim of disability.

The rheumatologist stated that refraining from work had never been proven to benefit a fibromyalgia patient, nor to worsen his/her condition. He stated, “The medical literature does not have an answer for this question. Further, if a treatment for fibromyalgia (activity limitation) is not efficacious, then abandonment of that mode of treatment (activity limitation) is the proper course.” He refused to change his opinion.

MetLife’s February 4, 2008 letter informed Minton that it was denying his claim essentially based on this rheumatologist’s opinion. Once again he was told that MetLife did not consider the evidence he had provided as adequate to support his claim that he could not perform the duties of his own occupation.

Disability Attorney Files ERISA Claim Against MetLife

Minton’s disability attorney filed an ERISA claim against the disability plan administrator. Because the plan gave MetLife discretionary authority to determine Minton’s eligibility for benefits, the appropriate standard with which to review MetLife’s decision was the abuse of discretion standard. Because MetLife also funded the plan, the Court would also consider whether conflict of interest may have colored MetLife’s decision. If this became apparent then the Court would weigh just how much influence this conflict might have had.

MetLife had never made it clear what additional material it needed from Minton. Previous Courts had found this failure unacceptable, so the Court also found that this suggested that MetLife’s decision needed to be considered “with a moderate amount of skepticism.”

Disability Attorney Argues Against MetLife Claim It Did Not Abuse Its Discretion

What did the record prove? MetLife refused to recognize a fact that the Courts have – that fibromyalgia “is diagnosed entirely on the basis of patients’ reports of pain and other symptoms,” and “there are no laboratory tests to confirm the diagnosis.” (See Benecke v. Barnhart, 2004.) Minton’s doctor had reminded the disability insurance plan of this fact. He had also performed tests to confirm the fact that his patient’s fibromyalgia resulted in functional limitations specific to his job.

MetLife had arbitrarily refused to give credit to this evidence. Instead, the disability benefit plan had preferred the opinion of a physician who demanded evidence which could not be obtained. This physician’s opinion that pain just couldn’t be severe enough to limit functioning when objective findings could not provide a cause has been disapproved of for over 20 years in the 9th Circuit.

The Court found that MetLife had set a standard which no one with fibromyalgia or chronic fatigue syndrome could ever meet, thus denying individuals with these conditions their rightful disability benefits in every situation. To do this, while also discounting the other evidence Minton had provided was an abuse of MetLife’s discretion.

MetLife Wrongfully Denied Long-term Disability Benefits

The Court found that MetLife had wrongfully denied Minton his long-term disability benefits. Finding that he was eligible for long-term disability benefits under the “own occupation” terms of the Deloitte and Touche USA LLP Plan that extended through the first 24 months from the time of his disability, the Court ruled that MetLife owed Minton the full amount due for these 24 months plus pre-judgment interest on the unpaid benefits. The Court also found that Minton had the right to file for attorney’s fees as a separate motion.

The Court did not find however that MetLife had ever evaluated Minton’s qualifications for benefits under the “any occupation” provisions of the disability insurance plan. The Court returned the power to make this decision (remand) to MetLife.

If MetLife finds that Minton does not qualify under this provision, the Court has made it clear that Minton’s disability attorney may re-open the case.