Opinion ID: 1359690
Heading Depth: 2
Heading Rank: 3

Heading: MetLife's Full and Fair Review of Hobson's Claim

Text: Section 503(2) of ERISA requires that claims for benefits be afforded a full and fair review by the appropriate named fiduciary of the decision denying the claim. 29 U.S.C. § 1133(2). The district court concluded that MetLife afforded Hobson such a review by reasonably t[aking] up each and every aspect of the claim. Hobson, No. 05 CV 7321, Tr. at 28. Hobson alleges that MetLife failed to fully and fairly review her benefits claim by (A) not notifying her of what additional information she needed to perfect her claim; (B) requiring objective support for her medical conditions; (C) failing to consider all the medical evidence she submitted; (D) giving undue weight to the opinions of MetLife's consultants over those of Hobson's treating physicians; (E) failing to request an independent medical examination, as provided for in its own policy; and (F) not considering the Social Security Administration's (SSA) finding of disability for the same medical conditions for which she requested LTD benefits from MetLife. We review each argument in turn and find each to be without merit.
Section 503(1) of ERISA contains a general requirement whereby, upon denying a claim for benefits, a plan administrator must provide the claimant with adequate notice in writing ... setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant. 29 U.S.C. § 1133(1). ERISA regulations further require that the administrator furnish the claimant with a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary .... 29 C.F.R. § 2560.503-1(g)(1)(iii). As we have explained, the purpose of ERISA's notice requirement is to provide claimants with enough information to prepare adequately for further administrative review or an appeal to the federal courts. Juliano v. Health Maint. Org. of NJ, 221 F.3d 279, 287 (2d Cir.2000) (internal quotation marks omitted). In past cases  including the two cited by Hobson  in which courts found that plan administrators failed to substantially comply with the ERISA notice requirement by not notifying claimants of information necessary to perfect their claims, the administrators also failed to explain the specific reasons for the benefit denial. See, e.g., Schleibaum v. Kmart Corp., 153 F.3d 496, 499 (7th Cir.1998); Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 694 (7th Cir.1992); Dzidzovic v. Bldg. Serv. 32B-J Health Fund, No. 02 CV 6140, 2006 WL 2266501, at , 11 (S.D.N.Y. Aug.7, 2006); Dawes v. First Unum Life Ins. Co., No. 91 Civ. 0103, 1992 WL 350778, at -5 (S.D.N.Y. Nov. 13, 1992). There is no question that MetLife communicated to Hobson its specific reasons for denying her LTD benefits. After Hobson alleged that she suffered from several conditions including debilitating depression, seizures, and Dercum's, MetLife's March 2005 letter explained why it concluded that she seem[s] to be functional. In terms of her depression, the letter stated that what is lacking is whether the depression would be severe enough to actually have suicidal ideation or whether this depression requires inpatient hospitalization. As for her seizures, the letter stated that what was lacking from [her] file was whether [she was] having ongoing seizures that are not well controlled and prevent [her] from driving or getting around. As for her Dercum's diagnosis, MetLife explained that Hobson's records lacked evidence that she exhibited four diagnostic criteria for Dercum's, and that there was no mention in the records of what type [of Dercum's she] allegedly ha[s] or a treatment plan for th[e] disease. The letter further stated that Hobson's colitis and thyroid cancer appeared to be cured by the surgical procedures she underwent, and that her medical records did not demonstrate that she was disabled due to spinal degenerative disease or debilitating migraines. It is noteworthy that after Hobson's initial claim for benefits was denied in November 2001 and she submitted additional medical information, MetLife granted Hobson LTD benefits on three separate occasions, thereby reflecting that MetLife reasonably took up each and every aspect of Hobson's claims. Juliano, 221 F.3d at 287. Finally, Hobson's ability to perfect her claim three times supports our conclusion that she was fairly apprised of how she could prepare adequately for subsequent appeals of earlier benefit denials. Id. Therefore, we are persuaded that MetLife substantially complied with ERISA's notice regulations.
Hobson alleges that MetLife failed to afford her full and fair review of her LTD benefits claim by requiring objective support for her medical conditions, because MetLife's own policy does not require such proof, and because this court has clarified that subjective complaints alone may constitute sufficient evidence of disability. See Connors v. Conn. Gen. Life Ins. Co., 272 F.3d 127, 136 (2d Cir.2001) (It has long been the law of this Circuit that the subjective element of pain is an important factor to be considered in determining disability.) (internal quotation marks omitted). This court has never directly addressed whether it is reasonable for a plan administrator, who retains the discretionary authority to interpret the terms of its plan, to require the plaintiff to produce objective medical evidence, where such a requirement is not expressly set out in the plan. However, several courts in this district have found that it is not unreasonable or arbitrary for a plan administrator to require the plaintiff to produce objective medical evidence of total disability in a claim for disability benefits. Fitzpatrick v. Bayer Corp., No. 04 Civ. 5134, 2008 WL 169318, at  (S.D.N.Y. Jan. 17, 2008); see also Suren v. Metro. Life Ins. Co., No. 07-CV-4439, 2008 WL 4104461, at  (E.D.N.Y. Aug. 29, 2008) (collecting cases and concluding that MetLife did not abuse its discretion when it based its opinion on objective tests and examinations, despite Suren's subjective complaints of fatigue and weakness). We conclude that it is not unreasonable for ERISA plan administrators to accord weight to objective evidence that a claimant's medical ailments are debilitating in order to guard against fraudulent or unsupported claims of disability. As the Eighth Circuit has explained, even in a claim involving fibromyalgia, trigger-point findings ... constitute objective evidence of the disease, and it is not unreasonable for a plan administrator to require such evidence so long as the claimant was so notified. Johnson v. Metro. Life Ins. Co., 437 F.3d 809, 813-14 (8th Cir.2006). When MetLife denied Hobson's initial appeal in March 2002, it informed her that there has been no documentation ... that substantiates documented trigger point tenderness that falls within the major criteria for the diagnosis of fibromyalgia. In light of this notification, MetLife acted within its discretion in requiring some objective evidence that Hobson was disabled from performing in a sedentary capacity. Such a requirement is not contradicted by any provision of MetLife's own policy, which provides that an employee's claim may be denied if she cannot obtain sufficient medical evidence to support her disability claim. By the terms of the Plan, MetLife retains the discretion to interpret what constitutes sufficient medical evidence, and MetLife's determination that such evidence requires objective support, rather than merely subjective reports of pain, is reasonable. In this case, MetLife's conclusion that Hobson's subjective pain did not rise to the level of rendering her unable to work was supported by Dr. Subrt, the very doctor who diagnosed Hobson with Dercum's, and who reached the same conclusion. Thus, we decline to hold that MetLife's decision to deny Hobson's claim for benefits, because she failed to provide objective evidence showing that she was disabled from sedentary work deprived her of full and fair review.
Hobson also alleges that MetLife did not properly consider all of her medical evidence, ignoring her non-physical ailments and co-morbid conditions, the impact of her medications, and her subjective complaints of pain. We have already rejected Hobson's allegation that MetLife ignored her subjective complaints in the prior section. We now turn to the remaining evidence which Hobson alleges that MetLife arbitrarily and capriciously ignored. There is no merit to Hobson's contentions that MetLife intentionally ignored evidence that she was disabled due to non-physical ailments and co-morbid conditions, that is, conditions that pertain to two or more disorders simultaneously  here, fatigue, inability to concentrate, cognitive functioning, and memory loss  and that MetLife should have evaluated such evidence together, rather than in isolation. MetLife had two independent psychiatrist consultants evaluate Hobson's file. The first concluded that Hobson's psychiatric and cognitive functioning [wa]s essentially within normal limits, that there were no objective findings of any cognitive impairment or problems with memory or cognition, and that her own correspondences indicated that her non-physical ailments did not impair her ability to function. The second explained that Hobson's depression did not render her unable to perform her duties, as MetLife mentioned in its March 2005 letter to Hobson. Thus, MetLife expressly considered Hobson's non-physical ailments and co-morbid conditions, and the two consultant reports that Metlife relied upon substantially supported MetLife's denial of Hobson's claim for LTD benefits. See Suren, 2008 WL 4104461, at  (finding that benefit denial was not arbitrary and capricious where independent physicians determined that claimant was not cognitively impaired). We are also not persuaded that MetLife abused its discretion by not taking into consideration the side effects Hobson allegedly suffered due to the daily medications she took to address her conditions. Hobson's brief failed to elaborate on this argument: Specifically, she failed to explain how exactly she had established to Metlife that her medications rendered her unable to work. For example, Hobson could have provided, but did not in fact provide, letters from her treating physicians opining that her medications hindered her functional abilities. As the Tenth Circuit explained in rejecting a similar claim, the question for this court is not whether MetLife made the `correct' decision [but] whether MetLife had a reasonable basis for the decision that it made. Chalker v. Raytheon Co., 291 Fed.Appx. 138, 145 (10th Cir.2008). Here, MetLife reasonably concluded that Hobson remained able to work, relying on the opinions of seven independent consultants, one of whom expressly stated that Hobson ha[d] been on medications for a considerable period of time, and these medications d[id] not give her side effects, according to the medical records reviewed, and another who explained that Hobson appeared cognitively functional, as indicated by her detailed and cogent communications with MetLife. In light of these evaluations, MetLife reasonably concluded that Hobson remained able to function despite taking various medications to treat her medical ailments.
Hobson also contends that MetLife gave undue weight to the opinions of the independent physicians it consulted, first by retaining those consultants, and then by affording more weight to those consultants' opinions than to those of Hobson's treating physicians. We find no merit to Hobson's argument. MetLife had a total of seven independent physicians, none of whom was a MetLife employee, and all of whom were Board-certified in one or more of the specialty areas relevant to Hobson's diagnoses and conditions, review Hobson's file. MetLife did not abuse its discretion by considering these trained physicians' opinions solely because they were selected, and presumably compensated, by Metlife. See Suren, 2008 WL 4104461, at  (That they were paid consultants does not disable MetLife from considering their opinions in making benefits decisions.). Indeed, it is customary for plan administrators to do so in evaluating ERISA claims. Second, MetLife is not required to accord the opinions of a claimant's treating physicians special weight, especially in light of contrary independent physician reports. Black & Decker, 538 U.S. at 834, 123 S.Ct. 1965. Moreover, nothing in the record indicates that MetLife arbitrarily refused to credit Hobson's medical evidence. MetLife's consultants repeatedly attempted to contact Hobson's treating physicians, several of whom concluded that Hobson's diagnoses and conditions did not inhibit her from working. Hobson specifically challenges MetLife's reliance on its independent physicians' reports in determining that she was not disabled due to Dercum's, which these physicians characterized as a rare affliction which nobody is sure about. However, as we have already noted, Hobson's own treating physician, the same one who sent a letter diagnosing Hobson with Dercum's, concluded that she was not disabled due to Dercum's. Thus, there is no merit to Hobson's argument that MetLife unreasonably relied upon speculative and unqualified physicians' opinions.
MetLife declined to order an in-person, independent medical examination (IME), as provided for in the Plan. In challenging MetLife's decision as arbitrary and capricious, Hobson relies on Chan v. Hartford Life Ins. Co., No. 02 Civ. 2943, 2004 WL 2002988 (S.D.N.Y. Sept. 8, 2004), in which the district court found that the plan administrator's failure to order an IME call[ed] into question its decision to terminate [claimant]'s benefits. Id. at . As in Chan, MetLife's benefits policy permits MetLife to order an in-person IME, indicating that such an evaluation is valuable in certain situations. The six listed situations include the following three: [c]larification when the stated diagnosis is not usually disabling, [t]he stated diagnosis is vague and supported only by subjective information, and [t]here are inconsistencies in the medical evidence or conflicting opinions from various medical examinations (i.e. ... the [SSA]). These factors, which comprise half of the enumerated factors, are present in Hobson's case. Consistent with its policy, MetLife could have ordered an IME because it explained to Hobson that her neurologic, gastroenterologic, and psychiatric conditions did not render her unable to perform a sedentary position, and because Hobson's claim was rejected due to her failure to provide objective evidence of the ailments she subjectively reported. Also, there were conflicting determinations as to whether Hobson's fibromyalgia was disabling, and Hobson was awarded social security disability benefits based on the same medical reports submitted to MetLife. However, as the four circuits that have addressed the question have concluded, where the ERISA plan administrator retains the discretion to interpret the terms of its plan, the administrator may elect not to conduct an IME, particularly where the claimant's medical evidence on its face fails to establish that she is disabled. [3] We share the Seventh Circuit's concern that requiring the plan administrator to order an IME, despite the absence of objective evidence supporting the applicant's claim for benefits, risks casting doubt upon, and inhibiting, the commonplace practice of doctors arriving at professional opinions after reviewing medical files, which reduces the financial burden of conducting repetitive tests and examinations. Davis v. Unum Life Ins. Co. of Am., 444 F.3d 569, 577 (7th Cir.2006). As in past sister circuit cases finding that a plan administrator need not order an IME, here, Hobson failed to produce sufficient objective evidence supporting her benefits claim. Moreover, several of her own treating physicians opined that she was able to return to work, thereby significantly undermining her benefits claim. Finally, the Plan's guidelines only list situations in which IMEs may be valuable, not where they are necessary. Because this court only disturbs a plan administrator's determination if it is arbitrary and capricious, we are unconvinced that the Plan obliged MetLife to conduct an IME; rather, by not ordering such an examination, MetLife simply exercised its discretion to decline to pursue one option at its disposal.
MetLife required Hobson to apply for social security disability benefits, and in May 2003, the SSA awarded Hobson such benefits on the basis that she suffered from colitis and fibromyalgia. Hobson alleges that both the district court and MetLife failed to consider her social security disability benefits award in making their LTD determinations. Where the administrator requires a claimant to pursue social security disability to reduce the amount of benefits due under the plan, Leffew v. Ford Motor Co., 258 Fed.Appx. 772, 778-779 (6th Cir.2007), and subsequently determines that the claimant is not entitled to ERISA benefits, the Sixth Circuit has counsel[led] a certain skepticism of a plan administrator's decision-making, Calvert, 409 F.3d at 295; see also Leffew, 258 Fed.Appx. at 779. Although the SSA's definition of the term disability is not necessarily coextensive with an ERISA plan's definition of that term, see Kunstenaar v. Conn. Gen. Life Ins. Co., 902 F.2d 181, 184 (2d Cir.1990), the Sixth Circuit nevertheless considers an award of social security disability benefits to be a relevant factor in determining whether a claimant is disabled under an ERISA plan, see Calvert, 409 F.3d at 295. Here, it does not appear that either MetLife or the district court considered the SSA's conclusion that Hobson was disabled, as that term is defined by the SSA; neither MetLife's letters denying Hobson's claim for LTD benefits nor the district court's decision discuss that conclusion. Still, between the time that Hobson submitted the diagnoses upon which the SSA awarded her disability benefits and August 2004, when MetLife sent her its next letter terminating her LTD ERISA benefits, she had undergone surgery for her colitis. MetLife terminated Hobson's benefits on the basis that she had successfully recovered from this surgery; thus, the SSA's determination as to her pre-surgical condition was no longer relevant when Metlife denied her benefits claim. Compare with Ladd v. ITT Corp., 148 F.3d 753, 755-56 (7th Cir.1998) (determining that the claim denial was irrational where the claimant's medical condition worsened after the SSA awarded her benefits but before the plan administrator denied her ERISA benefits). As for Hobson's fibromyalgia diagnosis, substantial evidence supported MetLife's determination that the condition did not render her disabled, as explained above. Supra Part II.A; see also Suren, 2008 WL 4104461, at  (In light of all the medical evidence in the record, ... [the court] cannot responsibly find [the administrator's] decision to be without reason....). We encourage plan administrators, in denying benefits claims, to explain their reasons for determining that claimants are not disabled where the SSA arrived at the opposite conclusion: Doing so furthers ERISA's goal of providing claimants with additional information to help them perfect their claims for subsequent appeals. See 29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1(g)(1)(iii). Nonetheless, especially in light of the substantial evidence supporting its determination, we decline to hold that MetLife's failure to do so in this case renders its denial of Hobson's LTD benefits claim arbitrary and capricious.