Fourth Circuit Holds ERISA Plaintiff Did Not Demonstrate Disability Due to Non-Limited Condition Under Terms of Disability Policy

In Penland v. Metropolitan Life Insurance Company, No. 24-1772, 2025 WL 1672861 (4th Cir. June 13, 2025), the Fourth Circuit considered Plaintiff Penland’s appeal of the district court’s determination that he did not meet his burden of proving entitlement to long-term disability benefits under his former employer’s plan that is administered by Metropolitan Life Insurance Company. The appellate court ruled against Penland. It acknowledged that Penland experiences significant pain but found that he was not entitled to payment beyond the MetLife policy’s 24-month limitation for disabilities due to conditions including neuromuscular, musculoskeletal, or soft tissue disorders.

MetLife initially approved Penland’s claim for LTD benefits after he ceased working in 2015 due to medical complications. Under his employer’s plan, benefits were contingent on proving an inability to earn more than 80% of predisability income due to sickness or injury. After paying benefits for the initial 24 months, MetLife terminated them in 2021, citing insufficient evidence of non-limited disabling conditions. Penland’s subsequent appeal included additional medical documentation, but MetLife upheld its decision, finding no objective evidence of conditions like radiculopathy. The district court initially affirmed MetLife’s denial using a modified summary judgment approach, which was later vacated by the Fourth Circuit due to procedural missteps highlighted in Tekmen v. Reliance Standard Life Insurance Co., 55 F.4th 951 (4th Cir. 2022). This led to a remand for a bench trial, where the district court once again supported MetLife’s decision. Penland appealed this ruling.

Penland presented three main arguments against the district court’s decision. First, Penland contended that the court misinterpreted the plan’s limitation provision by requiring him to prove disability without considering limited medical conditions. However, the court upheld the view that the term “due to” implies a but-for causation, meaning multiple factors could cause disability, and the plan’s plain language did not support Penland’s interpretation that non-limited conditions should be the sole cause. This reasoning aligns with established contract principles under ERISA, requiring terms to be enforced as per their ordinary meaning.

Second, Penland argued that his case fell under an exception to the limitation provision because he had objective evidence of radiculopathy, citing medical records from Dr. Jay Patel, who oversaw his pain management. The court found this argument unconvincing, as Dr. Patel’s notes lacked detailed rationale, and the MRI or interpreting physician’s findings were not present in the record. Moreover, independent consultants from MetLife found no evidence supporting radiculopathy, leading the court to determine that Penland did not meet the objective evidence requirement.

Third, Penland challenged the court’s finding that he failed to meet the burden of proving “Disability” under the plan. He argued that Nurse Cox’s opinion should have been weighed more heavily than MetLife’s independent consultants. However, the court noted that Nurse Cox’s conclusions were largely unsupported by detailed evidence and lacked a rationale for functional limitations. The court highlighted that under ERISA, administrators are not required to give special deference to treating physicians over other reliable evidence. Despite Penland’s concerns about the impact of the COVID-19 pandemic on his ability to gather evidence, the court found no clear error in its findings, noting that existing evidence could still have been used effectively.

Ultimately, the Fourth Circuit determined that the district court’s decision was informed by a thorough evaluation of objective evidence and adherence to ERISA principles, leading to an affirmation of MetLife’s denial of benefits.