In Diaz v. Metropolitan Life Insurance Company, No. 21-CV-679 (MJD/JFD), 2023 WL 112586 (D. Minn. Jan. 5, 2023), District Judge Michael J. Davis awarded further long-term disability (“LTD”) benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”), after determining that MetLife’s termination of Plaintiff’s claim after 24 months was arbitrary and capricious and, therefore, an abuse of discretion. In March 2017, Plaintiff was employed as a flight attendant for American Airlines when he fell off a roof and suffered a calcaneal fracture of his right foot. Plaintiff developed significant medical complications and underwent four surgeries between March and November 2020, as the injury failed to properly heal.
MetLife approved Plaintiff’s initial claim under his employer’s self-funded plan, and the employer paid LTD benefits for 24 months. MetLife then terminated benefits in June 2019, asserting that although it agreed the medical information supported that Plaintiff remained unable to perform the duties of a Flight Attendant, he did not meet the eligibility requirements under the “any occupation” definition of disability. The group LTD plan limits benefits to 24 months for disabilities caused by “neuromuscular, musculoskeletal and/or soft tissue disorders” and “disorders of the spine.”
Plaintiff appealed and submitted a letter from his foot and ankle specialist, as well as medical records and a series of photographs of his right foot. In his letter, the specialist referenced recent MRI imaging that showed the development of “avascular necrosis of the talus and calcaneus of the right foot. He also reported that recent imaging of Plaintiff’s lumbar spine showed mild disc space narrowing and spurring attributed to his fall. Noting Plaintiff’s “significant pain” and inability to stand and walk for any length of time, the specialist concluded that these symptoms and the need for extensive bracing and immobilization would preclude Plaintiff’s ability to return to work at even a sedentary level.
Due to an employee error at MetLife, the company’s decision on Plaintiff’s first appeal was not sent to him for four months, until January 7, 2020. In that letter, MetLife denied Plaintiff’s appeal based on a peer review that disagreed with the restrictions and limitations of Plaintiff’s treating providers. Plaintiff retained counsel who submitted a second administrative appeal. MetLife arranged for a medical review by a different peer reviewer, who concluded there was no evidence of imaging to support a diagnosis of avascular necrosis, and Plaintiff’s lumbar radiculopathy was not disabling. In its final decision letter, MetLife acknowledged that avascular necrosis is “a condition that is not limited by the Plan,” but relied on the peer reviewer’s assessment. MetLife also rejected Plaintiff’s lumbar radiculopathy diagnosis based on the peer review assessment of MRI imaging as non-impairing. Plaintiff filed suit.
On cross-motions for summary judgment, the Court disagreed with MetLife’s conclusions. It found that although MetLife did not abuse its discretion in denying Plaintiff’s claim based on lumbar radiculopathy, it did abuse its discretion in denying his claim based on avascular necrosis. The Court heavily criticized MetLife’s reliance on the peer reviewers’ conclusory assessments and noted that contrary to the second peer reviewer’s statement, the record was filled with evidence of medical imaging to support the claim of Plaintiff and his treating physicians that he suffers from avascular necrosis. This second peer reviewer did not explain why the medical imaging reports were insufficient. The Court also noted that its determination was further supported by procedural irregularities in the record, including that the peer review reports had to be returned by MetLife to the reviewing physicians on multiple occasions for “clarification” and the months’ long delay in communicating the company’s decision in the first administrative appeal. Even without these procedural irregularities, the Court found the record showed that MetLife abused its discretion by crediting the peer reviewer’s conclusory and ambiguous statement concerning Plaintiff’s avascular necrosis diagnosis over the reasoned conclusions of Plaintiff’s treating physicians.
As this case demonstrates, it can be difficult to convince insurers of continued disability even with medical imaging and treating physician support. If MetLife has denied or terminated your disability insurance claim, contact us for assistance.
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