Opinion ID: 2976436
Heading Depth: 3
Heading Rank: 3

Heading: MetLife’s Eligibility Determination

Text: We next consider Huffaker’s argument that MetLife’s denial of disability benefits was arbitrary and capricious. MetLife contends that its denial was based on Huffaker’s failure to prove her disabled status under the terms of the Plan, namely because she provided insufficient objective evidence of disability. We first address whether the terms of the Plan allow MetLife to require that Huffaker present objective evidence of her disabled status. We hold that it may. The Plan provides that a beneficiary will receive disability benefits once the beneficiary is disabled as defined by the Plan, after the completion of an elimination period. The Plan defines “disabled” as follows: Disabled or Disability: You are Disabled if, due to sickness or pregnancy or accidental injury for which you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis: -9- During the first 24 months that benefits under this Plan are paid to you, you are unable to perform each of the material duties of your Occupation. After benefits under this Plan are paid to you for 24 months, you are unable to engage in any business or occupation or to perform any work for compensation, gain or profit for which you are reasonably fitted by your education, training, background, or experience. This Court has previously held that a disability benefits plan employing similar eligibility requirements could require a claimant to provide objective evidence of disability. In Cooper v. Life Ins. Co. of N. America, we held that “[r]equiring a claimant to provide objective medical evidence of disability is not irrational or unreasonable.” Cooper v. Life Ins. Co. of N. America, 486 F.3d 157, 166 (6th Cir. 2007) (citing Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 361 (6th Cir. 2002)). The definition of “disability” at issue in Cooper required that the claimant prove inability to perform “all the material duties of his or her Regular Occupation,” id. at 159-60, and did not explicitly require the claimant to provide objective evidence of disability. We found the administrator’s objective-evidence-of-disability requirement reasonable, explaining that “[o]bjective medical documentation of [the claimant’s] functional capacity would have assisted [the administrator] in determining whether [the claimant] was capable of performing ‘all the material duties of her Regular Occupation,’ as required by the [long-term disability plan]’s definition of disability.” Id. at 166. Here, Huffaker must similarly prove she is “unable to perform each of the material duties of [her] Occupation” to satisfy the Plan’s definition of “disability.” As in Cooper, MetLife could reasonably interpret the Plan’s language to require objective evidence of disability. See also Michele v. NCR Corp., No. 94-3518, 1995 WL 296331, at  (6th Cir. May 15, 1995) (holding that the administrator did not act arbitrarily or capriciously in denying long-term disability benefits for -10- chronic fatigue syndrome where the plan requires proof of total disability from “a bodily injury or disease”; and the claimant failed to present sufficient objective medical evidence of total disability). A claimant could certainly find burdensome a requirement that she proffer objective evidence of fibromyalgia itself, the symptoms of which are largely subjective.2 But objective evidence of disability due to fibromyalgia can be furnished by a claimant without the same level of difficulty. See Boardman v. Prudential Ins. Co., 337 F.3d 9, 16-17 n.5 (1st Cir. 2003) (“While the diagnos[is] of . . . fibromyalgia may not lend [itself] to objective clinical findings, the physical limitations imposed by the symptoms of such illness[] do lend themselves to objective analysis.”). One method of objective proof of disability, for instance, is a functional capacity evaluation, a “reliable and objective method of gauging” the extent one can complete work-related tasks. Cooper, 486 F.3d at 176 (Sutton, J., concurring in part, dissenting in part). In Johnson v. Metropolitan Life Ins. Co., 437 F.3d 809 (8th Cir. 2006), the Eighth Circuit held that a “plan administrator [can] require objective evidence of a disability, even when the claimant’s alleged disability stem[s] from fibromyalgia, so long as the administrator notified the claimant that her file lacked the required objective evidence.” 2 The Seventh Circuit has aptly described the difficulties in diagnosing fibromyalgia: [F]ibromyalgia, also known as fibrositis[,] is a common, but elusive and mysterious, disease, much like chronic fatigue syndrome, with which it shares a number of features. Its cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia. The principal symptoms are “pain all over,” fatigue, disturbed sleep, stiffness, and-the only symptom that discriminates between it and other diseases of a rheumatic character-multiple tender spots, more precisely 18 fixed locations on the body (and the rule of thumb is that the patient must have at least 11 of them to be diagnosed as having fibromyalgia) that when pressed firmly cause the patient to flinch. Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 916 (7th Cir. 2003) (internal quotation marks, alterations, and citations omitted). -11- Id. at 814 (citing Pralutsky v. Metropolitan Life Ins. Co., 435 F.3d 833, 838-40 (8th Cir. 2006)). Here, MetLife notified Huffaker that her file lacked the required objective evidence in its December 22, 2004 letter denying benefits, which stated as its reason for denial: “There is no medical evidence provided by the treating sources to suggest a significant functional impairment or support the severity of this medical condition to prevent you from performing your job.” Thus, MetLife did not act unreasonably in requiring objective evidence of disability.
We now review whether MetLife’s eligibility determination was supported by the evidence. Huffaker contends that she provided MetLife with objective evidence of disability, and refers to three sources: Dr. Thomas, the neurologist; Dr. Bozeman, her family practitioner; and Anita Ferris, the physical therapist. In her argument on appeal that she is disabled under the Plan, however, the documentary evidence that Huffaker relies on from these sources consists of forms submitted to MetLife after MetLife’s February 10, 2005 denial of her internal appeal.3 We decline to consider this evidence, because in our review of MetLife’s decision, we are “strictly limited to a consideration of the information actually considered by the administrator.” Killian v. Healthsource Provident Admin., Inc., 152 F.3d 514, 522 (6th Cir. 1998). MetLife argues that the evidence considered by MetLife prior to its denial of her internal appeal on February 10, 2005, supports its finding that Huffaker was not disabled under the Plan. MetLife argues that Dr. Thomas’s findings do not support a finding of disability, referring to Dr. 3 The medical evidence from Dr. Bozeman consists of a medical information form addressed to the Social Security Administration, dated March 22, 2005. The medical evidence from Dr. Thomas consists of a medical information form supplied by Huffaker’s attorney, dated June 6, 2005. The medical evidence from Anita Ferris consists of a medical information form supplied by Huffaker’s attorney, dated June 8, 2005. -12- Thomas’s physical examination of Huffaker on May 18, 2004, in which she is described as “a wellnourished individual in no apparent distress.” Although Dr. Thomas’s treatment notes mention that the purpose of the consultation was to address Huffaker’s complaints of muscle cramps and pain described as “excruciating,” the medical documentation from Dr. Thomas under consideration by MetLife supports of its finding that she was not disabled. MetLife explains that it failed to accord great weight to Dr. Bozeman’s opinion that Huffaker was disabled because his opinion was “based on Huffaker’s self-reported complaints of pain, nothing more.” MetLife contends that his opinion is not supported by a functional capacity evaluation, and was contradicted by Dr. Bozeman’s findings that Huffaker’s muscle strength was normal in all extremities and that she had full range of motion in all joints, and by the negative results of the battery of tests that she underwent. MetLife did not discredit the findings of Anita Ferris, the physical therapist, on appeal. In Yeager, we observed that “complaints of fatigue and joint pain” are “types of subjective complaints [that] are easy to make, but almost impossible to refute.” Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 382 (6th Cir. 1996) (holding that absent any “definite anatomic explanation of [a claimant]’s symptoms,” an administrator’s decision to deny disability benefits due to fibromyalgia was not arbitrary and capricious); cf. Cooper, 486 F.3d at 174 (Sutton, J., concurring in part, dissenting in part) (“[S]ubjective complaints of back pain by themselves do not compel an administrator to grant disability benefits”). MetLife did not arbitrarily refuse to credit Dr. Bozeman’s findings given the inconsistency between Huffaker’s subjective complaints of pain and Dr. Bozeman’s findings of normal muscle strength and range of motion. -13-
Huffaker next argues that MetLife erred in its reliance on the independent medical examination of Dr. Uzzle. As her first reason, Huffaker argues that Dr. Uzzle, a doctor of orthopedic medicine, is unqualified to diagnosis fibromyalgia. She argues that a rheumatologist should instead have conducted the examination, because fibromyalgia is a rheumatological condition. But Huffaker cites no factual or legal authority for the proposition that only a rheumatologist may diagnose fibromyalgia. Her insistence on such a rule is inconsistent with her demand that great weight be given to the opinions of Dr. Thomas, a neurologist; Dr. Bozeman, a family practitioner; and her physical therapist, a non-physician. In any event, MetLife did in fact rely on the medical opinion of a rheumatologist, Dr. Ewald, who reviewed Huffaker’s medical file. Huffaker next challenges Dr. Uzzle’s credibility by arguing that he failed to address whether she had fibromyalgia. Our review of the content of Dr. Uzzle’s report, however, does not lead us to this conclusion. His report noted that he reviewed records from Dr. Bozeman and others, and that “[Huffaker] is at a point one would characterize as a diagnostic dilemma.” He specifically noted that “[f]ibromyalgia has been considered,” and concluded from his review of Huffaker’s medical records that she “has been thoroughly evaluated from the standpoint of multiple different specialties and in the end there has been no specific objective and verifiable anatomic problem to explain her varied symptomatology.” And he diagnosed Huffaker with “[c]hronic pain disorder.” The critical question for purposes of Huffaker’s eligibility for disability benefits is not whether she does or does not have fibromyalgia, but whether she is disabled under the plan. Dr. Uzzle’s conclusion after conducting a physical examination was that he could “find no objective basis why she cannot return to her work as a thrift store outlet manager at this point assuming she is psychologically capable of doing this.” -14- Huffaker then argues that MetLife failed to investigate her allegation that Dr. Uzzle did not examine her. But two physician file-reviewers, Drs. Ewald and DeSantis, examined Huffaker’s medical file, which included Dr. Uzzle’s findings. Their review of Dr. Uzzle’s findings indicates no basis for determining them unreliable. So even if MetLife did have a duty to investigate Huffaker’s allegation, that duty would have been satisfied by the file review undertaken by Drs. Ewald and DeSantis. Finally, Huffaker argues that MetLife erred in failing to investigate Dr. Uzzle’s concern that her complaints of pain might be psychosomatic. However, Huffaker never claimed a psychiatric impairment during the administrative process, but rather claimed that her disability was due to fibromyalgia. In any event, the administrative record includes treatment notes from a psychiatrist, from as late as January 1, 2005. Although the psychiatrist prescribed the medication Cymbalta, he did not diagnose any cognitive or functional limitations precluding her from working. Accordingly, we find that MetLife did not act arbitrarily or capriciously in relying on Dr. Uzzle’s medical opinion as a basis for the denial of benefits.
Huffaker next argues that MetLife erred in relying on the opinions of Drs. Ewald and DeSantis because reliance on non-examining medical sources is “disfavored,” and they ignored functional limitations diagnosed by Dr. Bozeman. But it is well-established that MetLife need not necessarily defer to the opinions of treating physicians. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). We have held that “[g]enerally, when a plan administrator chooses to rely upon the medical opinion of one doctor over that of another . . . the plan administrator's decision cannot be said to have been arbitrary and capricious.” McDonald v. W.-S. Life Ins. Co., 347 F.3d -15- 161, 169 (6th Cir. 2003). And we observed in Calvert v. Firstar Finance, Inc., 409 F.3d 286, 295 (6th Cir. 2005), that “reliance on a file review does not, standing alone, require the conclusion that [the administrator] acted improperly.” Thus, we “find nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination.” Id. at 296. Although “the failure to conduct a physical examination–especially where the right to do so is specifically reserved in the plan–may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination,” id. at 295, this case does not present such an instance. Here, MetLife obtained an independent medical examination, namely that of Dr. Uzzle. Dr. Uzzle’s examination of Huffaker, however, was unfavorable to her disability claim. He personally examined Huffaker and determined that she was not disabled, noting the absence of “specific objective and verifiable anatomic problem to explain her varied symptomatology.” Our review of Drs. Ewald and DeSantis’s reports indicates that they reviewed the findings of Dr. Bozeman, and each found that Huffaker’s medical record did not show the existence of a functional limitation that would prevent Huffaker from doing her job. Dr. DeSantis’s report mentions that she could find no actual physical medical condition that would keep [Huffaker] from being able to physically perform her job. Dr. Ewald concludes in his report that he could find no objective evidence in any of these records to substantiate functional limitations that would preclude her ability to perform in material duties of her medium exertion level job.” Because MetLife validly exercised its right to rely on the opinions of physicians other than the treating physician, see McDonald, 347 F.3d at 169, we find Huffaker’s claim of error with respect to Drs. Ewald and DeSantis without merit. -16-