A Federal Judge in Washington has decided that Met Life’s claim determination, to deny a claim for long term disability insurance benefits, must be reversed, where it determined that the claim decision was an abuse of discretion.
The claimant, a former flight attendant for American Airlines, suffered from pulmonary dysfunction and headaches. Her claim was denied by Met Life, and her administrative appeal, which provided extensive medical records, and other claim support, failed to alter Met Life’s claim determination.
On appeal, Met Life sought to have a peer review conducted, by Dr. Daniel Gerstenblitt, a regular reviewer in the disability insurance community. Dr. Gerstenblitt determined that there was no objective evidence to support disability, despite her doctor strongly advocating that her near daily debilitating headaches were impairing her ability to work.
The Court noted that Dr. Gerstenblitt’s medical review was “narrowly focused”, as he stated that he could “only look at objective medical evidence” and cannot substantiate the need for limitations or restrictions based upon self reported symptoms. The Court was troubled that Dr. Gerstenblitt was not clear about what objective evidence could be offered to substantiate the severity of her headaches.
The claimant was also awarded Social Security disability benefits. On a further appeal to the appeals committee, her claim was reviewed by other insurance friendly providers, including Dr. Sonne and Dr. Varpetian. Both doctors issues reports supporting the insurers’ desired outcome.
The Court criticized the claim review process, noting that the administrator may not pick and choose between portions of medical records, or ignore portions of records favorable to a claim in favor of other records to the contrary. The Court also found that credibility determinations are best handled by treating doctors rather than file reviewing doctors. As a result, the Court determined that the claim determination was not the product of a reasoned deliberate process, but, rather, was an abuse of discretion. Supporting its conclusion was the rejection and disregard of all supportive medical records, the failure to consider the award of Social Security, the failure to consider any subjective evidence, and the cherry picking of the records.
The Court thus ordered the claim back for a remand for further consideration.
Williams v. Met Life