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FEDERAL COURT FINDS METLIFE ABUSED ITS DISCRETION-ORDERS INSURER TO PAY LTD BENEFITS

The US District Court for the Eastern District of Michigan recently determined that LTD Insurer-MetLife wrongfully denied a claimant’s request for LTD benefits.

SMDA was retained by the claimant after her administrative remedies had been exhausted and suit had been filed. The client had been employed as an Audit Manager for Deloitte LLP when she developed a condition which caused orthostatic intolerance which resulted in unpredictable and intermittent dizziness and fainting spells. Her own doctors said that when these episodes occurred she must be able to lie down during the day.

MetLife obtained a paid paper review by an outside physician who determined that the Insured “may need to sit or lie down as needed.” Relying on this recommendation, MetLife’s in-house vocational reviewer then concluded that the claimant was capable of performing the duties of her own occupation because her employer would allow her to “sit as needed.”

Applying a deferential standard of review, the Court determined that MetLife’s denial decision was arbitrary and capricious:

A denial of benefits based on a reading of Dr. Friedman’s note that plaintiff “may need to sit or’ lie down” to require only sitting as an accommodation is arbitrary and capricious. Defendant arbitrarily disregarded the consistent opinions of both plaintiffs treating physician and Dr. Friedman that plaintiff may need to lie down while working in order to accommodate the substantial functional limitations arising from her orthostatic intolerance.

Plaintiff showed that, based on reliable medical evidence, lying down would be an accommodation possibly required for her to continue working. Defendant’s consultant agreed with this assessment. No part of plaintiffs job description or any assessment in the administrative record allows for plaintiff to lie down on the job. Defendant, rather than address this potential accommodation, read Dr. Friedman’s assessment not as it actually read, that plaintiff might need to sit or lay down based on her orthostatic intolerance, but instead that either sitting or lying down would do equally well.

That is not what Dr. Friedman said. If he had, then defendant would have offered a reasoned explanation for its denial: sitting would accommodate orthostatic intolerance, and plaintiffs job permitted sitting, so she would still have been able to earn more than eighty percent of her pre-disability earnings at her own job. Instead, what Dr.
Friedman said is that sitting or lying down might be required to accommodate plaintiff. Defendant was required, in assessing whether plaintiff could do her job with her substantial functional limitations, to assess the impact of her potential need to lay down on her ability to do her job. Defendant did not, and that failure renders its decision arbitrary and capricious.

FInding that MetLife abused its discretion, the Court remanded the matter to MetLife for the sole purpose of determining whether her employer could accommodate her need to lie down when she experienced an episode of orthostatic intolerance.