Addis v. The Limited Long-Term Disability Program, 2003 U.S.Dist.LEXIS 15325 (E.D.Pa. 3/30/2006)(Issues: Selective Review of Evidence; Remand or Reinstate).  The plaintiff, who worked as a store manager for Victoria’s Secret, had to cease working in 2003 due to multiple sclerosis which was initially diagnosed in 1998 and progressed in the ensuing years.  Her treating neurologist certified her total disability to the insurer, MetLife; however, without any input from a physician, the claim was denied.  Addis appealed, and simultaneously attempted to perform part-time light duty work; however, after a short period, based on her doctor’s instruction, Addis ceased working altogether.   

With her appeal, the plaintiff submitted additional documentation from her treating doctor, along with a hospital record documenting an exacerbation of her condition.  Nonetheless, the claim denial was upheld based on the recommendation of an “independent physician consultant” who had reviewed the records.  Litigation ensued, and the matter was presented to the court on cross-motions for summary judgment. 

The first issue the court addressed was the standard of review.  Although the court found no insurer financial bias since The Limited self-funded the benefit plan, it did identify procedural bias affecting the standard of review which could be found from self-serving paper reviews, selective review of the evidence, and disregarding recommendations of an insurer’s own employees.  The court examined the record and found that the record supported a finding that Addis’s condition deteriorated over time which was objectively corroborated by an increase in plaques in successive MRI scans.  Symptoms also worsened over time – both with respect to blurred vision, ambulation difficulties, and mental confusion, along with other symptoms.  The court also noted the findings of the treating neurologist who had extensive knowledge of the progression of the plaintiff’s symptoms which led to his recommendation that she cease working due to unpredictable periods of weakness, fatigue, incontinence, vision difficulties and cognitive problems.   

In response to the evidence from the treating doctor, the court pointed out that MetLife mischaracterized the treating doctor’s findings.  Moreover, the court was particularly critical of MetLife’s reliance on its consultant who had conducted a paper review of the medical records, Dr. Gary Greenhood – he lacked specialization in neurology and also performed a record review rather than an examination.  The court also found Dr. Greenhood “selectively viewed Addis’s medical records, and MetLife then selectively adopted parts of Dr. Greenhood’s report to support denial of the claim.” *19.  The court then focused on the following: 

MetLife deliberately chose to accept the opinions of its own physician, who was not a specialist, over those of the insured's treating physician, who was a specialist. Phillips relied exclusively on the report of Dr. Greenhood, an internist specializing in infectious disease. This unqualified reliance on its retained consultant ignored Addis's treating neurologist's opinions. The reviewer did not explain why she made this choice. Instead, she merely recited, without any analysis, portions of Dr. Greenhood's sparse report. *20-*21.

The court then held that while Black & Decker v. Nord, 538 U.S. 822 (2003) ruled that special deference need not be given to a treating doctor’s opinion, “it did not grant plan administrators a license to disregard or only cursorily consider the opinions of the physicians who were familiar with and treated the claimant.”  *21. The court added:

The Supreme Court's instruction does not authorize a plan to give conclusive weight to an unreliable report of a non-treating physician. Nor does it insulate plan decisionmakers every time they decide to overrule a treating physician's report in favor of a consultant's opinion. Nord, 538 U.S. at 834 ("Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician."). *22.

Of course, the court acknowledged that if a consultant’s “opinion is based on reliable evidence it can support a determination contrary to that of the treating physician, especially if the consultant is a specialist and the treating physician is not.”  *23.  However,

Conversely, where the treating physician is a specialist who has treated his patient over time and the insurer's non-specialist consultant has not, the plan may be required to explain why it relied on its consultant's evaluation and disregarded or only superficially considered the treating physician's findings. *23

The court therefore concluded that Dr. Greenhood’s findings did not support a benefit denial.  He was a non-specialist, his review was vague and selective, and evasive in disregarding complaints of fatigue substantiated by the treating doctor.  The court also found MetLife disregarded a second supporting medical opinion.  Thus, MetLife’s denial was found arbitrary and capricious and unsupported by substantial evidence.  Consequently, the court ordered the payment of benefits, rejecting MetLife’s request for a a remand under the following rationale:

ERISA promotes the interests of employees and other plan beneficiaries by protecting employees' contractually defined benefits. See McLeod v. Hartford Life & Acc. Ins. Co., 372 F.3d 618, 624 (3d Cir. 2004) (citing Firestone, 489 U.S. at 113). Allowing a plan administrator another opportunity to re-enforce its conclusion after many months and several layers of administrative proceedings during which it had ample time to conduct the necessary evaluation would undermine these underlying policies of ERISA. Carney, 2005 WL 21129851, at *5 (citing Zervos v. Verizon N.Y., Inc., 277 F.3d 635, 648 (2d Cir. 2002) and Caldwell v. Life Ins. Co. of North Am., 287 F.3d 1276, 1288-89 (10th Cir. 2002)). *34-*35.

Nor was the court willing to grant a remand for a determination of “any occupation” disability even though the MetLife determination was under the “own occupation” definition and the definition of disability had changed to a requirement that the insured be disabled from performing “any occupation” during the course of the litigation.  The court explained:

During the administrative process, more than 19 months transpired from the time MetLife originally declared Addis disabled and granted her benefits, and the time MetLife finally denied her claim, using the "own occupation" standard. In the meantime, MetLife received additional medical information updating her deteriorating condition and her functional limitations. The documentation generated by Addis's treating doctors covered the period beyond the first year of Addis's claimed disability. Nevertheless, MetLife's physician consultant, whether on his own or at MetLife's direction, determined Addis's limitations as of July 2003, six months into the disability period at issue. As observed earlier, this arbitrary cut-off date enabled the consultant and MetLife to ignore the medical evidence of Addis's condition and limitations beyond that date.

Remanding for further administrative proceedings at this time is not warranted. Medical knowledge of MS teaches that the disease is a progressive one with debilitating consequences for the afflicted. The medical evidence in this case proves the point. Addis's condition worsened and her limitations increased over the course of the review period itself. Thus, although the Plan may conduct further review of the plaintiff's continuing eligibility for benefits under the "any occupation" standard, past benefits under both tests of disability will be awarded to date. *36-*37.

Discussion:      This ruling is a powerful expose of a completely inadequate claim review.  What is troubling about this case, though, is the court’s characterization of Dr. Greenhood’s report as “carefully crafted.” *26.  Not every judge is going to be as thoughtful and deliberative as Judge Savage, and other judges might have mistaken the careful crafting of that report for an adequate review.  Discovery would have shown that Dr. Greenhood performs hundreds of file reviews for MetLife each year, further undermining his opinion.  Why this claim was even contested is a mystery given the constellation of symptoms and the objective evidence that the plaintiff’s condition was worsening.  Perhaps if MetLife had a neurologist review the file or perform an independent examination, litigation would have been unnecessary since the plaintiff’s disability was so evident. 

We also have to give kudos to Judge Savage for ordering the payment of benefits.  Under the circumstances presented, a remand would only have prolonged a foregone conclusion.  His opinion highlighted the defects in the claim process and reached a well-supported conclusion.