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Insurance Company Properly Denied Long-Term Disability Benefits After Reviewing Insuredís Previously Submitted Doctor Reports and Its Own Experts Reports

Rogers v. Metropolitan Life Ins. Co.
No. JKB-12-1012 (U.S. District Court for the District of Maryland, May 15, 2013)

by Anna C. Horevay, Summer Associate
Semmes, Bowen & Semmes (www.semmes.com)

This case concerns whether an insurance company adequately demonstrated that its decision to terminate disability benefits for an insured was a reasonable exercise of its discretion. Upon a motion for summary judgment, the United States District Court for the District of Maryland held that substantial evidence supported the insurance companyís decision to deny coverage as the company considered the opinions of both the plaintiffís experts and the opinions of independent physicians and vocational consultants.

Jessie Rogers, Plaintiff, began working with Greenhorne & OíMara, a consulting firm, in October 2000 as an Employee Services Specialist, which involved sedentary-type work. After her final day of work in 2008, Ms. Rogers had surgery for degenerative lumbar disk disorder. Under a policy issued by Metropolitan Life Insurance Company (ďMetLifeĒ), Ms. Rogers was approved for short-term disability benefits, but soon after applied for long-term disability benefits.

MetLife approved Ms. Rogers for long-term disability benefits, effective May 7, 2008. In her approval letter, MetLife notified Ms. Rogers of the planís definition of disability for both the first twenty-four (24) months of her disability and a different definition thereafter. Under the first twenty-four (24) month period, Ms. Rogers must be unable to earn ďmore than 80% of [Her] Predisability Earnings at [her] Own Occupation from any employer in [her] local Economy.Ē After the initial twenty-four- (24) month period, Ms. Rogers must be unable to earn ďmore than 80% of [her] Predisability Earnings from any employer in [Her] Local Economy at any gainful occupation for which [She] [is] reasonably qualified.Ē

Beginning in July 2010, Ms. Rogersís pain management center noted an improvement in her condition. Around that time, one of Ms. Rogersís doctors, Dr. McLellan, also indicated that she could work full-time at a sedentary job in any occupation with some limitations. On December 21, 2010, a second doctor, Dr. Genato, cleared Ms. Rogers for sedentary work.

Based on those doctor assessments and an independent assessment of Ms. Rogersís ability to obtain gainful employment, MetLife discontinued Ms. Rogersís benefits as of December 2, 2010. MetLife notified Ms. Rogers that she no longer met the second definition, which described the time after the initial twenty-four- (24) month period, of disability because she could find gainful, sedentary type work for which she qualified in her local economy.

After an initial appeal, MetLifeís independent consultant reviewed Ms. Rogersís file and also received a labor market survey of job positions in Ms. Rogersís locale. Subsequently, MetLife modified its earlier decision, giving a new termination date for her long-term benefits of December 21, 2010.

Ms. Rogers again appealed MetLifeís decision, and with her appeal she included a functional capacity evaluation by a vocational consultant and documentation from her doctor, Dr. Genato. MetLife asked a second consultant to review Ms. Rogersís file and the newly submitted information. MetLife forwarded its consultantís report to Ms. Rogersís physicians for review and comment; however, Ms. Rogers requested that MetLife rely on her previously submitted reports by Dr. Genato rather than have Dr. Genato submit a new report.

On February 2, 2012, MetLife informed Ms. Rogers of its decision to uphold its decision terminating her long-term disability benefits. That decision constituted an exhaustion of Ms. Rogersís administrative remedies. This suit followed, with Ms. Rogers arguing that MetLife abused its discretion by failing to conduct a full and fair review of her file.

Ms. Rogers argued that MetLife did not base its decision upon substantial evidence. MetLife argued that its determination was reasonable and supported by medical evidence within Ms. Rogersís file. The Court found MetLifeís determination reasonable and supported by medical evidence. The Court stated that MetLife did not base its decision solely on the opinions of its medical consultants or vocational consultants. Rather, MetLife gave considerable weight to the opinions of Ms. Rogersís own physicians, and MetLifeís decisions were consistent with Ms. Rogersís doctorsí assessments.

The Court also found that the additional functional capacity evaluations that Ms. Rogers submitted did not support her position. The evaluations that Ms. Rogers submitted reflected the same opinion as MetLifeís expertsóMs. Rogers demonstrated self-limited, submaximal effort during her evaluations. Because Ms. Rogersís poor efforts compromised the results of these evaluations, MetLife reasonably disregarded the evaluations that suggested Ms. Rogers was only able of completing part-time work, especially in light of the opinion of Ms. Rogersís physician who imposed no such limitation on her employment. As to Ms. Rogersís vocational consultant, the Court held that MetLife rightly gave no authoritative weight to his opinion because he failed to indicate how or why he was qualified to render an opinion as to functional capacity.

Because MetLife based its decision on a large record of information and properly assigned weight to expert opinions, the Court stated that Ms. Rogers cannot claim that MetLife abused its discretion in basing its decision on a lack of information. Further, the Court found that Ms. Rogers failed to explain what information was lacking to demonstrate that MetLife based its opinion on incomplete evidence. Accordingly, the Court affirmed the decision of MetLife and found that MetLife was entitled to summary judgment.