Disability Claim Denied

Workers in Grand Prairie, Fort Worth, Arlington, Irving, Dallas, Mansfield, Cedar Hill, Duncanville, Mesquite, Garland, and other places in the metroplex area would have an interest in the following case.
This a United States Court of Appeals for the Fifth Circuit case styled, Habiba Ewing v. Metropolitan Life Insurance Company. The opinion was issued on June 7, 2011, after an appeal from the district court. The appeals court confirmed the finding in favor of Metropolitan.
Here is some information:
Ewing worked for Shell Oil Company and was covered by the company’s long term disability benefits plan (“PLAN”). Metropolitan (MetLife) insures the payment of benefits under the plan and reviews claims filed thereunder. Ewing filed for long term disability benefits after Ewing injured her shoulder, leading to shoulder surgery followed by ongoing complaints of pain. MetLife denied her claim on the ground that she was not “disabled,” as the term is defined by the Plan. Ewing administratively appealed MetLife’s determination, but was unsuccessful.
The terms of the Plan grant MetLife “discretionary authority to interpret the terms of the plan and to determine eligibility for and entitlement to plan benefits in accordance with the terms of the plan.” This court pointed out that the law in this area of controversy says that where a plan governed by ERISA grants the administrator “discretionary authority with respect to the decision at issue,” the court is to look only for abuse of this discretion. The administrator’s decision must be supported by substantial evidence. “Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Ewing argued that MetLife abused its discretion by applying an incorrect definition of “disabled.” The Plan provided the following definition of disability:
that, due to an Injury or Sickness, you require the regular care and attendance of a Doctor and …:
1.a. During the Elimination Period [before long term disability payments become available] and the 24 month period immediately following the Elimination Period, you are unable to perform each of the material duties of your regular job or a Comparable Occupation with the Employer which the Employer will have offered to such Employee, provided a Comparable Occupation is available; and
b. after the first 24 months of benefit payments, you must be unable to perform each of the material duties of any gainful work or service for which you are reasonably qualified taking into consideration your training, education, experience and past earnings.
MetLife’s summary plan description provided a briefer but similar definition:
To qualify for LTD benefits you must be disabled; that is you must:
Be under a doctor’s care;
Be unable by reason of your illness or injury to perform the duties of your own job, or another job available within a participating company for which you are reasonably qualified, for at least 52 consecutive weeks;
Apply for benefits, including submitting medical evidence of disability acceptable to MetLife; and Obtain MetLife’s approval of your claim.
Ewing argued that MetLife misinterpreted these definitions by erroneously considering Ewing’s employer’s willingness to accommodate her symptoms when evaluating whether those symptoms prevented her from doing the duties of her job. The court disagreed, stating, “By the terms of both the Plan and the summary description, MetLife was required to consider whether Ewing’s injury or illness prevented her from performing the duties of her job or a comparable position within the company. It was not an abuse of discretion for MetLife to consider the employer’s accommodations as part of its inquiry into the scope of Ewing’s duties.”
Ewing next argued that MetLife abused its discretion by failing to employ a vocational rehabilitation expert. The court rejected this because it was not brought up at the district court level and to do it now, on appeal, was too late. But the court addressed this issue anyway saying that Ewing has not shown that it was an abuse of discretion to decline to employ a vocational rehabilitation expert in this case.
Ewing’s final argument was a procedural one. Ewing claimed the district court erred by not allowing Ewing to supplement the record with additional medical records. The court correctly pointed out that the law is clear in these ERISA cases. “The law of this circuit is that ‘when assessing factual questions, the district court is constrained to the evidence before the plan administrator.'”
ERISA cases can be very difficult. Only an experienced Insurance Law Attorney should be consulted on these types of cases. There are ways of defeating the decision of the plan administrator but it is difficult and requires careful work. Even then, the results cannot be guaranteed. However, in the event an administrator is denying a claim for benefits there is nothing to be lost by getting an attorney to look over the case.