Type of Claim: Long Term Disability ERISA.
Insurance Company: Metropolitan Life Insurance Company (MetLife).
Claimant’s Employer: Visteon Corporation.
Claimant’s Occupation / Job Position: Senior Human Relations Manager.
Disabilities: After a motor vehicle accident in 2008, the claimant suffered exacerbated preexisting problems that she had with her right shoulder, left knee, and neck. X-rays of the claimant’s neck, right shoulder, and knees showed degenerative changes. The previous MRI study on the claimant’s cervical spine revealed “a lot of progression of the degenerative change described at C5-C6.”
Definition of Disability: The subject Long Term Disability Policy defines “disabled” or “disability” as:
[D]ue to Sickness or as a direct result of accidental injury:
• You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
• During the first 24 months of Sickness or accidental injury, You are unable to perform each of the material duties of Your own job; and
• After such period, You are unable to perform the duties of any gainful occupation for which You are reasonably qualified taking into account Your training, education and experience.
Benefits Paid? Yes. MetLife approved the claimant for continuing LTD benefits under the “any gainful occupation” portion of the definition of “disability”.
Basis For Denial / Termination of Benefits: In the fall of 2014, MetLife’s Special Investigation Unit requested Ethos Risk Services to perform an Internet Data Investigation of the claimant’s activity on social media websites. On October 21, 2014, MetLife received the Internet Data Investigation Report containing information for social media cites Facebook, MyLife, Pinterest, Google+, and Linkedin. The report, based on the claimant’s own postings, disclosed that the claimant traveled from her residence in Northville, Michigan, to Chicago for dinner with friends on March 6, 2014, and attended a wedding on February 24, 2014. In addition, the report disclosed that the claimant was enrolled in a doctoral program through the Center for Values-Driven Leadership at Benedictine University in Illinois, with a graduation date of 2016. The report also indicated that the claimant had traveled Dubai to present a paper at a conference.
On December 15, 2014, MetLife sent the claimant a letter notifying her of MetLife’s decision to terminate her LTD benefits because the medical information showed that she purportedly no longer met the definition of disability. In its letter, MetLife cited certain medical records indicating improvement in the claimant’s medical impairments, as well as Dr. Peters’s report.
Procedural history: The claimant’s LTD benefits were terminated. On June 15, 2015, the claimant filed an appeal with MetLife and submitted additional medical records and notes from physical therapy. In connection with the appeal, MetLife referred Black’s claim file to Robert H. Bolt, M.D., an independent physician consultant (IPC) board-certified in orthopedic surgery, for his opinion on Black’s restrictions and limitations. Dr. Bolt issued an initial report and two supplemental reports. In his initial report, dated February 16, 2015, Dr. Bolt conducted an extensive review of Black’s medical file spanning 2008, just after the accident, through early 2015, noting her diagnoses of degenerative joint disease bilateral shoulders, degenerative joint disease bilateral knees, cervical spine spondylosis and radiculitis, low back pain secondary to deconditioning, and post traumatic stress disorder.
The Plaintiff sued Defendant MetLife, pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq., seeking review of MetLife’s decision to discontinue Black’s long-term disability benefits as of December 15, 2014. The parties filed cross motions for judgment based upon the Administrative Record.
Other important factors: In a call with MetLife, the claimant’s own physical therapist opined she could perform sedentary occupations (desk jobs), even with her impairments.
Key Physician Opinions:
Based on the Internet Data Investigation Report, MetLife obtained an updated clinical opinion from MetLife Senior Medical Director David S. Peters, M.D. Dr. Peters opined on the claimant’s restrictions and limitations as follows:
[T]here are significant cervical spine MRI findings and mildly decreased shoulder [range of motion]. Dr. Salamon has documented knee crepitation. Social media sites revealed her to be active and, in my opinion, restricted fulltime (8 hours daily) primarily seated work should be possible while continuing evaluation and treatment of her conditions. In my opinion, she should not be required to climb ladders and standing/walking should be limited to 20 minutes per hour and to a daily total of 2.5 hours. She should not be required to work at or above shoulder level on the affected side. Lifting/carrying/pushing/pulling should be limited to 10 pounds or less occasionally. She should be able to shift positions when seated and have 2-3 minute “stand and stretch” periods at least every hour in addition to standard morning, afternoon and lunch breaks. There is no detailed description of elbow, hand or wrist impairments and constant handling, feeling, fine fingering and grasping should be possible.
After her benefits were terminated, the claimant appealed. In connection with the appeal, MetLife referred Black’s claim file to Robert H. Bolt, M.D., an “independent physician consultant” (IPC) board-certified in orthopedic surgery, for his opinion on Black’s restrictions and limitations. Dr. Bolt issued an initial report and two supplemental reports.
On April 29, 2015, Dr. Bolt issued his second supplemental report based on new information from MetLife regarding the course requirements for the claimant’s graduate studies. Dr. Bolt stated:
This [new information] does change my opinion. It states fairly clearly what is required of Ms. Black and, since she is getting a 4.0 GPA, she must be following those requirements. From this description it appears that Mrs. Black can sit unlimited in an 8 hour day. She should be able to change positions as needed to standing and stretching for 5 to 10 minutes. As far as standing and walking is concerned, I feel that she does have some limitations and could stand and walk no more than 2 hour [sic] cumulatively in an 8 hour day but total work time could add up to 8 hours. I reviewed the Diary Notes hoping to find a recent conversation with Ms. Black where she described exactly what she does for her classes but that did not appear to be available. Also missing from the record are clinical reports from Dr. Neuschwander [sic] and Dr. Salamon’s response to my report which is still pending.
Issues: “The administrative record in this case leaves no doubt that the 2008 accident exacerbated preexisting conditions that Black had in her knees, right shoulder, and neck and that these injuries caused her pain which precluded her from performing the duties of her position at Visteon. There is also no question that Black continued to suffer from the pain and effects of her injuries over the next several years. The question for this Court, however, is whether Black’s functional capacity showed improvement to the point that she was able to perform the duties of a sedentary occupation at the time MetLife terminated her benefits.”
Holdings: “The evidence MetLife received in 2014, and in 2015 after Black appealed MetLife’s initial denial, showed that Black’s physical condition had in fact improved sufficiently to allow her to perform sedentary work.”
Noteworthy court comments: “The Policy required Black to submit proof, satisfactory to MetLife, that she continued to be disabled not just from performing the duties of her prior occupation with Visteon, but “any gainful occupation for which [she was] reasonably qualified taking into account [her] training, education, and experience.” Pursuant to this provision, Black had the burden of proving that she continued to be disabled; MetLife was not obligated to prove that Black was not disabled.”
“Black argues that MetLife’s reliance on the attendance requirements of the Benedictine doctoral program—full days at least one weekend per month—and Black’s trip to Dubai as part of that program to conclude that Black is not disabled from performing full-time work is “absurd” because the number of days Black spent attending class (approximately 56 per year) is much less than the approximately 250 days per year that Black would be required to spend at full-time employment. While Black is correct that her attendance at the doctoral program cannot be equated to full-time work, her class attendance (as well as the out-of-class work she did toward completion of that program) is still material to whether she was disabled. First, her participation in the program, including travel to Illinois and attendance of classes at least one weekend per month, shows that she was not as limited as she claimed. For example, in her January 15, 2015, letter to MetLife, Black said that she could not “be up for more than a few hours and must rest . . . [and was] in constant pain.” The fact that Black was able to travel several hours and sit through daylong classes shows that Black was not as limited as she claimed. Second, the fact that Black was able to earn and maintain a 4.0 GPA in a doctoral program—certainly no easy feat—undermines Dr.Neuenschwander’s opinion that Black suffered from ‘extreme fatigue, easy fatigability [sic], brain dysfunction (consistent with traumatic brain injury) and PTSD symptoms.’”
Summary: The Court denied the plaintiff’s motion, granted MetLife’s motion, and affirmed MetLife’s decision to discontinue benefits.