District Court Finds Plaintiff Failed to Establish Ongoing Disability Due to Conditions Not Limited Under the Long-Term Disability Plan

In Penland v. Metropolitan Life Insurance Company, No. CV 8:21-3000-HMH, 2024 WL 3327366 (D.S.C. July 8, 2024), South Carolina District Judge Henry M Herlong, Jr., on remand from the Fourth Circuit, granted judgment in favor of MetLife finding that Plaintiff failed to establish that he continued to be disabled as of the date MetLife discontinued benefits under an ERISA-governed long-term disability plan.

Plaintiff was employed as a Regional Procurement Specialist for Continental Automotive, Inc. when he stopped working due to gastrointestinal issues after contracting E. Coli in 2014 and his ensuing colon resection surgery, as well as a number of other health issues, including degenerative joint disease in his right hip, depression, cervical and lumbar degenerative disc disease, psoriasis, cervical kyphosis, sleep apnea, nerve damage in his left leg, and osteoarthritis in his left big toe. MetLife approved LTD benefits in February 2016, noting at the time that Plaintiff’s disability was due to a neuromuscular, musculoskeletal or soft tissue disorder, which is a condition that is limited to 24 months of payments under the disability plan sponsored by Plaintiff’s employer.

On January 11, 2021, MetLife terminated benefits, after an independent physician review, noting that as of December 12, 2018, Plaintiff’s claim was supported based on conditions of cervical and lumbar degenerative disc disease which, under the Plan, are conditions limited to 24 months of benefits. The maximum duration end date for these conditions was December 11, 2020. MetLife acknowledged Plaintiff’s ongoing gastrointestinal conditions but found based on its physician consultant reviews that these conditions did not support restrictions and/or limitations beyond December 12, 2018. Plaintiff appealed, submitting additional treatment records, including c-spine and lumbar MRIs. On peer review, MetLife’s physician consultant concluded that while Plaintiff had evidence of cord compression at the level of C4/5, there was no evidence of radiculopathy, no abnormal cord signal nor any evidence of motor/sensory impairments in bilateral upper extremities. The physician reviewer also found that functional limitations were not warranted for Plaintiff’s other conditions. Based on this information, MetLife upheld the denial on appeal. The instant action ensued.

As an initial matter, the Court found that a de novo standard of review applied to Plaintiff’s claim as the plan language requiring proof of disability “satisfactory to MetLife” was not sufficient to confer discretionary authority. In reviewing the available evidence, the Court concluded that Plaintiff had not provided sufficient proof of ongoing disability as of the date MetLife discontinued benefits. The Court declined to consider evidence relevant to Plaintiff’s diagnoses of anxiety, depression, carpal tunnel syndrome, osteoarthritis, and degenerative disc and joint disease as Plaintiff was already paid the maximum 24 months of benefits for disability due to these conditions. The Court also rejected Plaintiff’s argument that notwithstanding the limitation, the cumulative effect of both limited and non-limited conditions should be considered, as this argument was based on a flawed reading of the Plan language.

The Court further found that Plaintiff had not presented “objective evidence” of radiculopathy as explicitly required by the Plan language, and that both peer reviewers independently confirmed no evidence of radiculopathy in the medical records. Finally, the Court found that Plaintiff’s remaining conditions did not prevent Plaintiff from earning more than 60 percent of his pre-disability salary. The only restrictions and limitations offered by treating providers related to Plaintiff’s cervical and lumbar degenerative disease. Both of MetLife’s consulting physicians found that there were no functional limitations found in the medical records stemming from Plaintiff’s GERD, gastroparesis, sleep apnea, type 2 diabetes, psoriasis, neuropathy, diverticulitis, fatty liver disease, pharyngoesophageal dysphagia, ulcerative colitis, pelvic floor dysfunction, or migraine headaches. The Court agreed that Plaintiff’s records provided little to no support for any functional limitations.

If MetLife or your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.