{"id":7548,"date":"2020-04-27T18:55:04","date_gmt":"2020-04-27T23:55:04","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7548"},"modified":"2024-04-15T15:17:15","modified_gmt":"2024-04-15T20:17:15","slug":"randall-v-metlife-doctors-conclusion-outweighs-subjective-complaints","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/randall-v-metlife-doctors-conclusion-outweighs-subjective-complaints\/","title":{"rendered":"Randall v. MetLife – Doctor’s Conclusion Outweighs Subjective Complaints"},"content":{"rendered":"\n

Case Name: <\/strong>Randall v. Metropolitan Life Insurance Company<\/p>\n\n\n\n

Court: <\/strong>United States District Court for the Northern District of California<\/p>\n\n\n\n

Date of Decision: <\/strong>February 6, 2017<\/p>\n\n\n\n

Type of Claims:\u00a0<\/strong>Short-term disability, long-term disability<\/a>, and related health, dental, vision, and life insurance benefits.<\/p>\n\n\n\n

Insurance Company: <\/strong>Metropolitan Life Insurance Company, aka MetLife<\/a>.<\/p>\n\n\n\n

Claimant\u2019s Employer: <\/strong>Verizon Wireless<\/p>\n\n\n\n

Claimant\u2019s Occupation \/ Job Position: <\/strong>Facilities Network Engineer<\/p>\n\n\n\n

Disabilities:\u00a0<\/strong>Randall suffers from \u201ca longstanding condition of chronic and severe\u00a0mid back pain<\/a>,\u201d which has progressed over time. She has a history of breast cancer<\/a> and has received diagnoses of anterolisthesis,\u00a0cervical disc disease<\/a>,\u00a0osteoporosis<\/a>,\u00a0lupus<\/a>, myofascial pain syndrome,\u00a0anxiety<\/a>, and\u00a0depression<\/a>. Randall now alleges that her back pain is exacerbated by sitting, standing, reaching, or keyboarding and that her pain, fatigue, and impaired concentration due to pain medication make it impossible for her to perform the essential functions of her job.<\/p>\n\n\n\n

Definition of Disability Under the STD Plan:  <\/strong>Randall\u2019s plan provided for Short Term Disability benefits for up to 26 weeks if she was found to be totally disabled. A \u201cTotal Disability\u201d is defined under the plan as follows:<\/p>\n\n\n\n

\n

You are considered totally disabled under the Plan for purposes of [Short Term Disability] benefits if, as a result of illness, injury or pregnancy, MetLife determines that you meet all of these conditions:
\u2022 You are absent from work for at least 8 full consecutive calendar days beginning with and including your first day absent from work because you are unable to perform for any Employer the Essential Functions of Your Occupation1 for which you are qualified by training, education or experience; and
\u2022 You have provided to MetLife objective medical evidence that sufficiently evidences, as determined by MetLife, that you cannot perform the Essential Functions of Your Occupation for which you are qualified by training, education or experience for any Employer. Your ability to get to and from the work place is not considered when determining whether you cannot perform the Essential Functions of Your Occupation if driving is not an Essential Function of Your Occupation . . .
\u2022 You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
\u2022 You are unable to earn more than 80% of your pre-disability earnings at Your Occupation; and
\u2022 You are not engaged in any job\/occupation, including self-employment, during the [Short Term Disability] application process or while you are receiving [Short Term Disability] benefits; and
\u2022 All information or documents to be considered has been received during the Initial Administration Period of your . . . claim.<\/p>\n<\/blockquote>\n\n\n\n

Other Important Provisions: <\/strong>The Plan stated that Randall was \u201cresponsible for proving [her] disability claim.\u201d Id. It instructed that she \u201cmust return a signed authorization form to MetLife allowing [her] Physician(s) to release objective medical evidence to substantiate [her] condition and ongoing treatment, as determined by MetLife,\u201d and that benefits would automatically \u201cbe denied if [she or her] doctor or qualified practitioner fails to provide objective medical evidence in support of [her] claim within the time period specified by MetLife.\u201d Id. The Plan specifically stated that \u201c[a] physician\u2019s note stating\u201d that Randall \u201cshould not work is not objective medical evidence sufficient to prove [her] claim.\u201d<\/p>\n\n\n\n

The Plan specifically stated that \u201c[a] physician\u2019s note stating\u201d that Randall \u201cshould not work is not objective medical evidence<\/a> sufficient to prove [her] claim.\u201d<\/p>\n\n\n\n

The Plan provided some guidance as to objective medical evidence:<\/p>\n\n\n\n

\n

Objective medical evidence is necessary to clinically substantiate your condition and includes, but is not limited to:
\u2022 A diagnosis of your medical condition.
\u2022 Objective findings such as test results, X rays or operative notes supporting your claim for benefits.
\u2022 Any other information related to your individual circumstances that MetLife determines is necessary to decide whether your claim should be approved or denied.
\u2022 You and\/or your Physician(s) may be required to provide additional information to substantiate ongoing treatment and\/or evidence to support your continuing claim for short term disability benefits. The costs associated with providing this information are your responsibility.<\/p>\n<\/blockquote>\n\n\n\n

Definition of Disability Under the LTD Plan: <\/strong>The LTD Plan\u2019s summary plan description (\u201cSPD\u201d) explains that \u201cYou will be eligible for LTD [Long Term Disability] benefits if you are continuously disabled and unable to return to work after receiving [Short Term Disability] benefits for 26-weeks\u2014provided you are certified as disabled under the LTD benefit component of the Managed Disability Plan and meet all other requirements detailed below.\u201d The relevant sections of the Plan define LTD as follows:<\/p>\n\n\n\n

You are considered disabled if MetLife determines that you have experienced, on or after the effective date of your LTD coverage under the LTD benefit component of the Managed Disability Plan, a significant change in your physical or mental condition as a result of accidental injury, sickness, mental illness, substance abuse or pregnancy.<\/p>\n\n\n\n

Under the LTD benefit component of the Managed Disability Plan, an employee is considered to be \u201cdisabled\u201d when the employee is absent from work because of an impairment for which there is sufficient objective medical evidence that supports:<\/p>\n\n\n\n

\n

For the first 24 month<\/a>s beginning with the LTD Effective Date:
\u2022 The employee cannot perform the Essential Functions of his or her job at Verizon Wireless.
\u2022 The employee cannot perform the Essential Functions of his or her occupation for which he or she is qualified by training, education or experience for any Employer.
For the period after the first 24 months beginning with the LTD Effective Date:
\u2022 The employee cannot perform the Essential Functions of any occupation for which he or she is qualified by training, education, or experience for any Employer.<\/p>\n\n\n\n

During the period of disability, the employee must:
\u2022 Be receiving Appropriate Care and Treatment and complying with the requirements of such treatment;
\u2022 For LTD benefits, during the qualifying period and the next 24 months of sickness or accidental injury, the employee must not be able to earn more than 80% of the employee\u2019s pre-disability earnings at the employee\u2019s own occupation for any employer in the employee\u2019s local economy. After the expiration of the qualifying period and the next 24 months, the employee must not be able to earn more than 60% of the employee\u2019s pre-disability earnings from any employer in the employer\u2019s local economy at any Gainful Occupation for which the employee is reasonably qualified taking into account the employee\u2019s training, education and experience.<\/p>\n<\/blockquote>\n\n\n\n

The LTD Plan also speaks to \u201cDisability Due to Mental or Nervous Disorders or Diseases, Neuromusculoskeletal and Soft Tissue Disorders, Chronic Fatigue Syndrome and Related Conditions.\u201d The Plan limits benefits for disability caused by mental or nervous disorders or neuromusculoskeletal and soft tissue disorders to a maximum of 24 months.<\/p>\n\n\n\n

However, Randall\u2019s plan also indicates that the \u201ccertificate of insurance\u201d governs the determination of her long-term disability benefits. The certificate of insurance states:<\/p>\n\n\n\n

\n

Disabled or Disability means that, due to Sickness or as a direct result of an accidental injury:
\u2022 You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
\u2022 You are unable to earn:
\u2022 During the Elimination Period and the next 24 months of Sickness or accidental injury, more than 80% of Your Predisability Earnings at Your Own Occupation from any employer in Your Local Economy.<\/p>\n<\/blockquote>\n\n\n\n

Benefits Paid?\u00a0<\/strong>MetLife approved short-term disability benefits for Randall from April 15, 2013, through May 6, 2013, but communicated to Randall on June 15, 2013, that benefits would not be approved beginning May 7, 2013.<\/p>\n\n\n\n

Issues: <\/strong>The Court determined whether Randall \u201cwas entitled to benefits based on the evidence in the administrative record and \u2018other evidence as might be admissible\u2026 .\u201d<\/p>\n\n\n\n

Holdings: <\/strong>“The Court concludes that Randall has failed to prove by a preponderance of the evidence that she was disabled from May 7, 2013, onward and therefore that MetLife did not err in denying her benefits.\u201d<\/p>\n\n\n\n

Noteworthy court comments: <\/strong>\u201cWhile it is clear that Randall was diagnosed with several conditions and was experiencing pain, she has not proven that she was disabled and unable to perform the essential functions of her job.\u201d
\u2026
\u201cRandall argues, in essence, that her consistent reports of pain and resulting diagnoses should be sufficient to establish by a preponderance of the evidence that she was disabled. Her consistent reports of subjective pain are not sufficient to find disability in the face of her doctors\u2019 uniform conclusions that she should return to work.\u201d<\/p>\n\n\n\n

\n

Disclaimer: Disability attorney Nick A. Ortiz<\/a> did not handle this case. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.<\/p>\n

Here is a PDF copy of the decision: Randall v. MetLife<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

Case Name: Randall v. Metropolitan Life Insurance Company Court: United States District Court for the Northern District of California Date of Decision: February 6, 2017 Type of Claims:\u00a0Short-term disability, long-term disability, and related health, dental, vision, and life insurance benefits. Insurance Company: Metropolitan Life Insurance Company, aka MetLife. Claimant\u2019s Employer: Verizon Wireless Claimant\u2019s Occupation \/ Job Position: Facilities Network Engineer Disabilities:\u00a0Randall …<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[258],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7548"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7548"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7548\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7548"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7548"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7548"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}