In this case, Teresa A. Seeman (“Seeman”) was an employee of Bank of America and served as a Vice President, Unit Manager from May of 1990 to December of 2007. Through her employment, she was part of a long term disability plan that was administered by Metropolitan Life Insurance Company (“MetLife”). The plan defined “disability” as follows:
“‘Disabled’ or ‘disability’ means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a doctor on a continuing basis unless, in the opinion of the Doctor, future and continued treatment would be of no benefit; and
- During the first 24 months, excluding your Elimination Period, you are unable to earn more than 80% of your Predictability Earnings or Indexed Pre-disability Earnings at your Own Occupation for any employer in your Local Economy; or
- After the first 24 month period, you are able to earn more than 60% of your Index Pre-disability Earnings from any employer in your local Economy at any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Pre-disability Earnings.”
By June 2008, MetLife had begun to pay out benefits for Seeman’s inability to work. This came as the result of diagnoses of Fibromyalgia and Chronic Fatigue Syndrome. Seeman then filed for and received long term disability benefits. These were paid out for two years, when MetLife terminated them. At this point, Seeman appealed to an administrative law judge who opined that Seeman’s “own testimony [wa]s inconsistent with the disabling level of physical or mental impairments.” She then exhausted her administrative remedies before filing the present suit on April 19, 2012.
Overall, the court was unable to “conclude whether Seeman’s physical diagnosis rendered her ‘disabled’ under the heightened post-June 3, 2010 standard” as defined above. Further, the court then remanded the matter to MetLife “to evaluate whether Seeman remained disabled under the post-June 3, 2010, disability standard” because “more information is required about how Seeman’s physical diagnoses affected her earning capacity.”
Following the remand, MetLife conducted a paper review of Seeman’s file through three Independent Physician Consultants. Dr. Robert S. Friedman stated that the “medical information provided does not support limitations due to [CFS] or [FMS]” and that “[u]nderlying psychiatric issues have significant impact on [FMS] and the perception of pain.” Next, Dr. Jennifer Rooke examined Seeman’s file and determined that she did not have any limited functionality as the result of physical conditions as of June 2010. Lastly Dr. Randy Rummler decided that there “was no evidence of psychiatric diagnosis or treatment during the relevant time period.”
MetLife had one additional doctor look over Seeman’s file. Dr. Louise Sheffield believed that Seeman was able to:
“stand occasionally, walk occasionally (less than 1 hour per day) and sit frequently . . . Climb steps less than one hour per day, bend and squat occasionally, twist less than one hour per day, reach frequently, light gripping and pinching frequently; firm gripping/pinching less than one hour per day; above shoulder reaching occasionally; and wr[i]te occasionally.”
Shortly thereafter, MetLife had two vocational experts conduct an Employability Assessment for Seeman. The report indicated that the job required working more than forty hours a week and involved sitting, standing, and walking. After all of these reviews, MetLife terminated Seeman’s benefits because she “[did] not satisfy the definition of disability set forth in the employer’s Plan.” Seeman stated that she would appeal that decision, and MetLife in turn stated that it would affirm its decision. MetLife then submitted a final letter of termination of benefits. Seeman appealed again, and the decision was again upheld, leading to this immediate action.
Seeman argues two major positions. First, she claims that because MetLife both pays the long term disability benefits and administers the claim, there is a conflict of interest. The court overall decided that it did not have enough information to decide whether the conflict of interest affected the final outcome of Seeman’s claim. Therefore, it explained that minimal weight would be given to its analysis of that issue.
Second, she claims that MetLife failed to consider any physical diagnoses she had and how those might affect her earning capacity. More specifically, she alleges that MetLife selectively used both the medical record and vocational reports. Alternatively, MetLife argues that the file does not support the vocational expert’s conclusions because Seeman’s complaints were subjective. MetLife also states that it is reasonable for it to request objective evidence. However, the court opined that the diagnoses of CFS and FMS “cannot be established via objective tests ” and “it is an abuse of discretion for a plan administrator to demand objective tests establishing the existence of a condition for which there [are] no such tests.”
More specifically, the court believed that such evidence would be needed for MetLife’s doctors to determine whether Seeman is disabled under the plan’s definition. The court agreed that this is so even with Seeman’s submission of symptoms of her CFS and FMS diagnoses: “trigger points” pain, inability to stand, walk, or sit comfortably for long periods of time, and fatigue. Further, the court discussed the fact that MetLife also relied on the opinion of the administrative law judge regarding the Social Security Disability Income benefits. The court then decided that while that reliance can be a factor of abuse of discretion, it is not necessarily the only standard. However, the court could not overlook the other factors that caused MetLife to appear to be arbitrary and capricious.
In the end, the court ruled that it was unable to locate support as to why MetLife should not grant long term disability benefits. As a result, it ruled in favor of Seeman and against MetLife. Seeman also requested interest from before the judgment and for after the judgment until paid. The court granted this for Seeman at the applicable rates.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: