Opinion ID: 1359690
Heading Depth: 2
Heading Rank: 2

Heading: Substantial Evidence Supporting MetLife's Determination

Text: Under the arbitrary and capricious standard of review, we may overturn an administrator's decision to deny ERISA benefits only if it was without reason, unsupported by substantial evidence or erroneous as a matter of law. This scope of review is narrow[;] thus[,] we are not free to substitute our own judgment for that of [the insurer] as if we were considering the issue of eligibility anew. Pagan, 52 F.3d at 442 (internal quotation marks and citations omitted). Hobson contends that MetLife's decision is not supported by substantial evidence because MetLife relied on its paid medical reviewers' speculative inferences, despite the reliable evidence of Hobson's doctors, and specifically relied upon Dr. Nesta's report, even though he failed to consider fibromyalgia in his review and only presented opinions [that] were at best `generic.' After August 2004, MetLife took five actions, each of which had the effect of disallowing Hobson's claim for LTD benefits: (A) the August 2004 termination of benefits after she recovered from colitis-related surgery; (B) the December 2004 termination after she recovered from thyroid cancer surgery; (C) the March 2005 denial of Hobson's first appeal after the thirty-six month period had passed; (D) the May 5, 2005 denial of benefits after additional review; and (E) the May 19, 2005 refusal to consider further appeals despite two letters Hobson submitted from attending physicians. [2] We evaluate each of these actions in turn.
First, we conclude that MetLife's termination of Hobson's LTD benefits after she underwent surgery to address her colitis was not arbitrary and capricious. The report prepared in 2004 by Dr. Nesta, the independent physician consulted by MetLife, concluded that Hobson's alleged impairments did not preclude her from working. Specifically, Dr. Nesta determined that Hobson's surgery should have cured her ulcerative colitis, the MRI and her neurologist's progress notes indicated that she did not have significant radiculopathy, and her neurologist's decision to not take Hobson out of work indicated that he could not find any neurologic basis for [Hobson's] seizures and migraines. As for Hobson's asthma, fungal infection, and fibromyalgia, Dr. Nesta determined that these conditions were not disabling. Hobson's own infectious disease specialist agreed that her fungal infection did not prevent her from working. Although her treating internist d[id] not agree that most of her ailments do not preclude her from working because he was concerned about her yeast infection, he did not submit additional information to support Hobson's claim for benefits. In fact, he conceded that there was insufficient data to determine her ability to work. Hobson specifically challenges on appeal MetLife's reliance on Dr. Nesta's 2004 report because Metlife failed to consider fibromyalgia in his review. Upon evaluating Hobson's final diagnosis of fibromyalgia, Dr. Nesta's report again concluded that fibromyalgia does not usually preclude an individual from working. Two years earlier, however, Dr. Nesta explained why he concluded that Hobson was not disabled due to her fibromyalgia: Hobson had no documented trigger point tenderness which is normally part of a fibromyalgia diagnosis, no hard evidence ... substantiate[d] her disability from a rheumatologic viewpoint, and her neurological examinations were normal. Moreover, Dr. Lieberman, another independent consultant who evaluated Hobson's record in 2001, opined that there wasn't any substantial global or objective evidence to support the opinion that Hobson was unable to perform any occupation because of her fibromyalgia; instead, Dr. Lieberman stated that [t]here certainly are a wide range of treatments available for patients with fibromyalgia to allow them to be more productive, gainfully employed, and have a better quality of life. As the Supreme Court has explained, courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). Thus, MetLife acted within its discretion in relying upon the conclusions of its independent consultants' three reports. Because the three reports provided detailed, substantive analysis of Hobson's fibromyalgia, we cannot find that MetLife unreasonably failed to consider Hobson's fibromyalgia. As Hobson's own treating physician conceded, it is far from clear that Hobson's medical records demonstrated that she was disabled; rather, we find ample evidence in Hobson's file to support MetLife's determination that she failed to make this showing.
In December 2004, after reinstating Hobson's LTD benefits when she underwent surgery for thyroid cancer, MetLife terminated her benefits. Metlife reasonably concluded that Hobson was not disabled, given that the same physician who operated on Hobson's thyroid cancer also recommended that she return to work in January 2005. Thus, the record substantially supports MetLife's termination of her LTD benefits, a decision we do not find arbitrary and capricious.
In appealing the denial of her benefits claim, Hobson submitted a report from Dr. Subrt diagnosing her with Dercum's and an updated evaluation from Dr. Sessoms explaining that Hobson's symptoms included several chronic medical conditions. Substantial evidence in the record supports MetLife's determination that Hobson was not disabled due to Dercum's. As the first consultant, internist Dr. Blair D. Truxal, explained, Dr. Subrt's letter consisted only of one brief paragraph, which Hobson supplemented with fourteen pages of information on [Dercum's] disease... researched from the Internet. Dr. Truxal concluded that no diagnostic criteria or physical findings supported the diagnosis. In fact, he pointed to four diagnostic criteria that Hobson lacked. Finally, Dr. Truxal explained that Hobson's records did not specify which of the three types of Dercum's she allegedly had, or mention any treatment plan for the disease. MetLife's additional determination that none of Hobson's other alleged ailments precluded her from work was not unreasonable. The second consultant, neurologist and psychiatrist Dr. John F. Delaney, Jr. opined that, although Hobson had a number of chronic medical conditions which are severe, she remained functional and was able to work without any difficulty at her sedentary job. Because MetLife was entitled to rely on these written reports, Black & Decker, 538 U.S. at 834, 123 S.Ct. 1965, its denial of Hobson's claim was neither arbitrary nor capricious.
Upon granting Hobson's request for additional review of the denial of her LTD benefits claim, MetLife referred Hobson's file to two additional physicians. Both reports support MetLife's decision to uphold its benefit denial. The first report from a psychiatrist concluded that Hobson was not cognitively impaired because she had not submitted any complete psychiatric or mental status examination supporting her claim, and seemed able to communicate cogently in writing with MetLife. The second report provided additional support for MetLife's determination that Hobson was not disabled due to Dercum's. The consultant, a dermatologist, opined that Hobson herself, rather than a doctor, had diagnosed herself with Dercum's, and that no objective evidence accompanied her subjective reports of pain to demonstrate that she was disabled. Hobson's own physician, Dr. Subrt, who wrote the letter stating his belief that she had Dercum's, conceded that he d[id] not feel that Ms. Hobson [wa]s disabled and d[id not] understand why she cannot do her job, which is sedentary. Because Hobson's treating physician and two independent consultants all opined that Hobson was not disabled from working, we find that MetLife's decision to uphold its denial of her claim for benefits fell squarely within its discretion.
Both of the letters Hobson submitted after MetLife informed her that it would not consider any further appeals failed to provide additional, objective evidence that she was disabled. The first letter from Dr. Subrt merely clarified that he was not qualified to opine on whether she suffered non-dermatologic disabilities, and explained that he did not discern any dermatologic disability. The second letter from Hobson's psychologist stated that Hobson was unable to function or work due to her depression, but did not include or append any evidence substantiating this conclusion. In light of the substantial evidence in Hobson's file supporting MetLife's determination that she was not disabled from sedentary work, we find that MetLife did not abuse its discretion in May 2005 by refusing to consider Hobson's request for a further appeal.