Opinion ID: 1767685
Heading Depth: 2
Heading Rank: 1

Heading: MetLife's review

Text: First, we must address the issue of what evidence MetLife was required to review, and, thus, what evidence we should review in making our decision. Selmon's disability benefits were terminated by MetLife in June 2001. During the review process, however, Selmon submitted information regarding his medical condition for the two years after his benefits were terminated. In reaching its decision on review, MetLife did not consider Selmon's medical condition after June 2001. In its letter explaining that decision, MetLife simply stated it did not consider any medical information regarding Selmon's condition after June 2001 because the review concerned only the termination of his benefits in 2001 and his condition at that time. Selmon contends his condition has only worsened since his benefits were terminated, and MetLife erred in not considering the new medical information, namely the emergency room records indicating he had suffered a sixth heart attack in July 2003. We agree with MetLife's decision to limit its review. Because Selmon was no longer a participant in the Great Lakes plan after June 2001, MetLife was not required to consider his medical condition after that date. Accordingly, we cannot conclude that MetLife abused its discretion in limiting its review to the evidence leading up to and including June 2001. The following evidence was before MetLife for consideration on review:  In 1997 Selmon suffered a heart attack, and he returned to work.  In February 1998, Selmon suffered a second heart attack while at work, and Dr. Bruce E. Murphy performed an angioplasty and a cardiac catheterization of his right and left coronary arteries.  In March 1998, Dr. Murphy noted no improvement in Selmon's condition and restricted his activities to limited stress situations and limited interpersonal relations.  Later that month, Selmon suffered a third heart attack, and Dr. D. Andrew Henry performed an emergency angioplasty and catheterization of Selmon's right coronary artery.  Selmon began receiving temporary total disability benefits under the Great Lakes plan in April 1998.  On June 17, 1998, Dr. Larry Ezell advised MetLife that Selmon was unable to work at that time due to his coronary artery disease. Specifically, Dr. Ezell indicated that Selmon, who was required to lift up to 75 pounds in his job, could not lift the requisite weight. MetLife contacted Selmon that month and he indicated that he still had some chest pain during exertion, but that he had cut his smoking from four packs of cigarettes a day to one pack a day.  On August 11, 1998, Dr. David Mego conducted a treadmill stress test and noted that Selmon had a good exercise tolerance with an excellent prognosis and index symptoms at a high cardiac workload. That same day, Dr. Murphy reported that Selmon had occasional chest pain with heavy exertion and otherwise had no complaints, and he noted that Selmon still smoked at least one pack of cigarettes a day.  On August 20, 1998, Dr. Murphy opined that Selmon could return to work and perform all of his regular duties at Great Lakes, but Selmon could not be exposed to the chemicals and fumes at the Great Lakes plant.  On November 24, 1998, Dr. Ezell examined Selmon and reported that Selmon said he had continued chest discomfort with moderate exertion such as doing yardwork or light housework, or experiencing stress.  In January 1999, Selmon's attending physician indicated to MetLife that Selmon could return to work, but the physician stated that Selmon would only be able to sit, stand, or walk for one hour at a time and could only lift up to ten pounds continuously.  In August 1999, MetLife contacted Selmon's attending physician who again indicated that Selmon's condition was stable and he could return to work but not in an environment with fumes and chemicals. A stress test conducted by Dr. Will L. Posey showed improvement in Selmon's heart rate while exercising, normal left ventricular systolic function, and the test was negative for stress-induced myocardial ischemia.  On February 10, 2000, Dr. Posey conducted another stress test on Selmon. He reported that Selmon was able to exercise for ten minutes without incident, and Selmon denied any chest discomfort even with peak exercise. Dr. Posey concluded that the test was negative for stress-induced myocardial ischemia.  On February 14, 2000, Selmon reported to Dr. Ezell that he still had chest pain whenever doing upper body torso work and could walk only short distances without stopping to rest.  In March 2000, a MetLife representative discussed available vocational rehabilitative services with Selmon, but he stated that he had been experiencing mood swings and did not feel mentally able to work, or to participate in any rehabilitative services.  MetLife did not receive any other medical records regarding Selmon for over a year. Upon contacting Dr. Ezell's office in April 2001, MetLife learned that Selmon had not been to see Dr. Ezell since March 2000, even though Dr. Ezell had instructed Selmon to return for a check-up every three months. The nurse who discussed Selmon's case specifically stated that Selmon had been noncompliant with the doctor's orders.  On June 13, 2001, Selmon finally returned to see Dr. Ezell. Dr. Ezell reported that Selmon complained of severe chest pain and shortness of breath and indicated that he was incapable of even mowing his yard or doing the most menial tasks. Dr. Ezell discussed coronary bypass grafting with Selmon, but Selmon indicated that he would rather wait until he had another heart attack before considering the procedure. Dr. Ezell warned Selmon that if he waited for another heart attack he could experience sudden cardiac death or permanent irreversible cardiac damage, but Selmon still refused the surgery.  On June 15, 2001, MetLife sent a letter to Selmon stating that his long-term disability benefits had been terminated, effective June 1, 2001. The letter listed the reason for terminating the benefits as Selmon's failure to remain in a physician's regular care and failure to provide updated medical records to support his position that he was still disabled.  Also on June 15, 2001, Selmon was examined by Dr. Aldo Fonticiella who found that Selmon had a reduced left ventricular systolic function with an ejection fraction of 43% and normal left ventricular internal diameter. Five days later, on June 20, 2001, Dr. Fonticiella reported that Selmon had a mildly reduced LV systolic function with an ejection fraction of 50%, and a 15% lesion in the right coronary artery.  In August 2001, when MetLife contacted Dr. Ezell, concerning Selmon's June 2001 condition, he indicated that he did not consider Selmon to be disabled, and he would release Selmon for work, but not at Great Lakes.  In July 2003, MetLife hired an independent cardiologist, Dr. Chandrakant Pujara to perform an independent medical evaluation of Selmon's condition in June 2001. Dr. Pujara reviewed Selmon's medical records along with notes from Selmon's attending physicians and concluded that, in 2001, Selmon should have been able to perform physical work without much limitation. After reviewing the above stated evidence, MetLife sent a letter to Selmon on September 19, 2003, upholding its decision to terminate his benefits in 2001. MetLife upheld its decision based again upon Selmon's failure to regularly see a doctor and provide MetLife with documentation of his condition. MetLife also based its decision on the June 2001 findings of Dr. Fonticiella that Selmon had a 50% ejection fraction, no obstructive disease of the coronary arteries, and only a 15% lesion in the right coronary artery. In sum, MetLife determined that the information provided by Dr. Fonticiella did not indicate that Selmon was unable to return to work as of June 1, 2001. Given the evidence detailed above, we cannot say that MetLife abused its discretion in determining that Selmon was not totally disabled as of June 2001, and in thereby terminating his benefits. Under the terms of the Great Lakes plan, a claimant will be considered totally disabled during the first twenty-four months after the injury and the qualifying period, upon proof that he cannot perform the duties of his job at Great Lakes. To be considered totally disabled after the first twenty-four months, a claimant must prove that he is unable to engage in  any occupation or employment that the claimant is or becomes qualified to perform due to education, training, or experience. In a civil action for denial of benefits, it is the claimant's burden plan to demonstrate that he is disabled under the terms of the ERISA plan and that he qualifies for benefits. See 29 U.S.C. § 1132(a)(1)(B) (1999); Farley v. Benefit Trust Life Ins. Co., 979 F.2d 653 (8th Cir.1992). Here, as early as August 1998, Selmon's doctors indicated that he would be able to return to work, even manual labor, but could not work around the fumes and chemicals at Great Lakes. In 1999, Selmon's attending physicians indicated that he did have some physical limitations, such as the amount of weight he could lift and the amount of time he could spend sitting, standing, or walking, but ultimately the physicians concluded that his condition was stable and he would be able to return to work. In late 1999 and early 2000, Selmon's treadmill stress tests produced negative results for stress-induced myocardial ischemia. He could complete the tests without incident, exercising for up to ten minutes without chest pain. His doctors also repeatedly noted that Selmon was continuing to smoke up to one pack of cigarettes a day, despite his past heart attacks. After March 2000, we do not have any indication of Selmon's medical condition until June 2001. During Selmon's June 2001 visit, Dr. Ezell discussed bypass surgery with Selmon, indicating that the surgery would improve his condition, but Selmon refused the surgery. When asked about Selmon's condition at that time, Dr. Ezell indicated that he did not consider Selmon disabled and would release him to work, but not to his former job at Great Lakes. In June 2001, Dr. Fonticiella found no obstructive disease in Selmon's coronary arteries, noted a 43% ejection fraction on June 15, 2001, and reported a 50% ejection fraction on June 20, 2001. Selmon claims that MetLife should have recognized that an ejection fraction under 50% is abnormal. Such an assertion, however, ignores the fact that MetLife was presented with evidence of a 50% ejection fraction on June 20, 2001. Finally, upon reviewing the medical notes of Selmon's attending physicians, Dr. Pujara, the independent reviewing physician, reached the conclusion that Selmon could return to work, including performing physical labor. The evidence in the administrative record does not establish that Selmon was unable to perform any work that he was qualified to do. Yet, Selmon asserts that his doctors continually concluded that he was totally disabled. In fact, the record shows that his doctors only concluded that he could not perform his job at Great Lakes, but not that he was completely unable to perform any job. Thus, based upon the above evidence, we cannot say that MetLife abused its discretion in finding that Selmon was not totally disabled under the Great Lakes plan and, therefore, was not entitled to benefits. Selmon nonetheless asserts that MetLife abused its discretion because it relied completely on the opinion of its own doctor, Dr. Pujara, to reach its decision. He claims that MetLife should have given deference to his attending physicians and concluded that based upon their notes and opinions, he was totally disabled. In Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003), the United States Supreme Court held that ERISA plan administrators are not obliged to accord special deference to the opinions of a claimant's treating physicians. Id. at 825, 123 S.Ct. 1965. The Court stated, however, that plan administrators may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. Id. at 834, 123 S.Ct. 1965. Selmon cites Burch v. Hartford Life & Accident Insurance Co., 383 F.Supp.2d 1119 (W.D.Ark.2005), as support for his assertion that MetLife arbitrarily refused to credit the evidence from his attending physicians. His reliance on Burch is misplaced. The decision in that case is distinguishable on its facts. In Burch , the claimant was diagnosed with fibromyalgia and osteoarthritis in the knees and ankles, and she underwent several surgeries to her feet. Id. at 1122-23. She was unable to stand without pain or sit for an extended period with her feet in a dependent position without severe swelling in her feet. Id. at 1123. Thus, the claimant's two attending physicians concluded that due to the progressive decline in her condition, the claimant was unable to perform even sedentary work. Id. at 1123. An independent reviewing physician concluded that the attending physicians had not given sufficient reasons for why the claimant could not perform sedentary work and determined that she could perform sedentary work with flexibility of position changes. Id. at 1124. In reaching its decision to terminate benefits, the plan administrator relied upon the independent physician's conclusions, which were in direct contrast to the information provided by the attending physicians. Id. at 1125-26. Accordingly, the district court held that the plan administrator had abused its discretion in terminating the claimant's benefits. Id. Here, unlike in Burch , the opinions of Selmon's attending physicians do not in fact conflict with that of Dr. Pujara, the independent reviewing physician. Dr. Pujara reviewed the attending physician's notes and concluded that in 2001, Selmon could have returned to work, even physical labor. As late as 2000, Selmon's own doctors indicated that his condition was stable and he might be able to return to work. Further, Dr. Ezell commented to MetLife in 2001 that Selmon was not disabled, and he would release Selmon to work, although not at Great Lakes. Thus, here, the independent physician's conclusion is in line with that of Selmon's attending physician-that Selmon was not completely unable to do any work.