District Court Construes ERISA Plan’s Objective Evidence Requirement Liberally In Favor of Claimant

In Sutton v. Metropolitan Life Insurance Company, et al., No. 222CV00732KJMCKD, 2023 WL 4669994 (E.D. Cal. July 20, 2023), the California Eastern District Court granted judgment in favor of Plaintiff, finding that he was entitled to continued LTD benefits beyond the 24-month neuromuscular or musculoskeletal condition limitation period based on objective evidence of myelopathy, which was an exception to the limitation.

Application of the 24-month neuromuscular or musculoskeletal condition limitation is the narrow issue of this case. The parties did not dispute Plaintiff was disabled under the terms of the plan, nor did they dispute his condition was neuromuscular and/or musculoskeletal. They disputed whether his condition fell within the exceptions to the limitation. According to the plan, an employee with a neuromuscular or musculoskeletal condition may continue to receive benefits beyond 24 months if “the Disability has objective evidence of” at least one of six listed conditions, including “Myelopathies” and “Spinal Cord Damage.”

MetLife informed Plaintiff in early 2021 that it would not offer benefits beyond 24 months because it had found no “objective evidence” of myelopathy or spinal cord damage.  Plaintiff, through his counsel, appealed. In response, MetLife retained a physician, board certified in physical medicine, rehabilitation, and pain medicine, to review Plaintiff’s medical records. The peer reviewer found no “objective evidence of myelopathy.” MetLife forwarded the peer review to Plaintiff’s counsel, who responded with additional medical records, including a 2021 MRI and x-ray, which had not been completed at the time of MetLife’s original denial, and a letter from Plaintiff’s pain management specialist opining that Plaintiff was totally disabled due to low back pain, but no specific diagnosis of spinal cord damage or myelopathy. This additional information did not change the peer reviewer’s assessment. Upon notification of such, Plaintiff’s counsel argued that MetLife had required more evidence from Plaintiff than the plan actually demanded, and he pointed out that Plaintiff’s symptoms, such as pain, numbness, and absent reflexes in his legs, could be attributable to myelopathy. MetLife upheld its decision on appeal after its peer reviewer again stood by his opinion that Plaintiff had not identified any objective evidence of myelopathy.

Under a de novo standard of review, the Court examined the disputed phrase to determine what the plan language meant when it said a “disability has objective evidence of” myelopathies or spinal cord damage.  The Court concluded that the term “disability” referred to a status that is satisfied by several conditions: (1) sickness or accidental injury; (2) receiving and complying with appropriate care and treatment’ and (3) inability to earn previous income due to sickness or injury. Reasoning that the term “disability” is an explanation of what purpose the “objective evidence” will serve, not the possessor of that evidence, the Court interpreted the disputed phrase as requiring objective evidence of myelopathy or spinal cord damage among the evidence offered to support the conclusion that a plan participant is disabled.

The Court noted, however, that the plan does not say how conclusive or extensive the “objective evidence” must be but asks simply for evidence “of” myelopathy or spinal cord damage. It reasoned that by asking for “objective evidence of” myelopathy or spinal cord damage, the plan could quite reasonably be asking for some objective evidence—any objective evidence—that tends to prove the existence of these conditions. The plan does not demand evidence “proving” or “establishing” myelopathy. Construing the plan in favor of coverage and resolving ambiguities in Plaintiff’s favor. The Court interpreted the plan as requiring only some objective evidence tending to establish myelopathy or spinal cord damage among whatever other evidence supports or refutes the conclusion that the plan participant is disabled.

The Court noted that Plaintiff’s medical records were lengthy and sometimes contradictory. In 2018. Plaintiff’s physician recorded a diagnosis of myelopathy but did not reference any testing supporting the diagnosis. Another medical record notes a 2018 MRI as showing moderate central spinal stenosis and stenosis can, in turn, damage the spinal cord or cause myelopathy. Other portions of Plaintiff’s medical records expressly ruled out myelopathy but did not connect this assessment to any specific imaging or test results. And yet, MetLife’s claims personnel repeatedly wrote in the record that Plaintiff was out of work “due to intervertebral lumbar disorder with myelopathy, lumbar region,” among other conditions.

The Court further remarked that some of the evidence, including reports of pain and numbness, were subjective. But some of the evidence in the record was objective, including clinical observations of reduced or absent reflexes, and MRI reports of spinal stenosis which can cause myelopathy. While these clinical observations and imaging reports did not prove Plaintiff suffered from myelopathy or even excluded other potential causes of his back pain, the court reminded that the plan does not require this sort of conclusive proof.

The Court did not find MetLife’s arguments minimizing the evidence were convincing. It noted, the peer reviewer’s opinion that the absence of reflexes does not suggest myelopathy by itself, should not be afforded dispositive weight given the plan does not require objective evidence excluding all causes. To the extent that some of Plaintiff’s physicians and their reports did not mention myelopathy, the Court found no policy provision that would allow MetLife to deny benefits based on negative inferences.  Moreover, doctors’ notes and opinions are not “objective evidence.”

As this case demonstrates, a continued award of benefits is dependent upon a proper interpretation of the plan language. If MetLife has improperly denied or terminated your disability claim, contact us for assistance.