Limitations Provision Upheld Against Long-Term Disability Plan Participant

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Metropolitan Life Insurance Co.'s decision that a long-term disability plan participant's benefits were subject to a plan provision limiting benefits for certain disabilities to 24 months was not arbitrary and capricious, the U.S. District Court for the District of Massachusetts ruled Sept. 21 (Brien v. Metropolitan Life Insurance Co., D. Mass., No. 1:11-cv-10395-DJC, 9/21/12).

The participant argued that he was disabled due to a combination of disabilities, including several that were excluded from the plan's 24-month limitation provision, and that MetLife's decision limiting his benefits was unreasonable.

Judge Denise J. Casper determined that MetLife did not act arbitrarily and capriciously because its decision regarding the participant's disabilities was reasoned and supported by substantial evidence.

Disability Benefits Limited.

Peter Brien worked for Ferguson Enterprises Inc. and participated in its Employee Retirement Income Security Act-governed employee welfare benefits plan. MetLife served as the plan's claims administrator and had discretion to interpret plan terms and determine benefit eligibility.

Under the plan, a participant was disabled if he or she was unable to earn 80 percent of pre-disability income during the first two years of disability and 60 percent of pre-disability earnings after two years. The plan provided disability benefits up to age 67 if the participant was disabled before age 62. The plan limited disability benefits to 24 months if the participant was disabled due to neuromusculoskeletal and soft-tissue disorders. Six specific conditions were excluded from the limitation provision and were eligible for the plan's full disability benefits.

Brien was injured in a car accident in July 2007, which may have been caused by a seizure after he failed to take his epilepsy medication. Brien was admitted to a hospital and diagnosed with spinal compression fractures.

Brien was unable to work due to the compression fractures and filed a long-term disability benefits claim. MetLife granted the claim in December 2007 but determined that Brien's disability was subject to the plan's limitation provision.

MetLife terminated Brien's long-term disability benefits in October 2009 after providing benefits for 24 months. Brien appealed MetLife's decision twice and argued that the decision was unreasonable because his past and current medical conditions “clearly” satisfied the policy's disability definition.

MetLife upheld its benefit decision following both appeals after having three independent physicians review Brien's records. Brien sued and both parties moved for judgment on the administrative record.

Benefit Decision 'Reasoned.'

Brien argued that his disability was not subject to the plan's limitations provision because several impairments contributed to his disability that did not fall under the limitations provision. Brien also alleged that objective evidence existed that he suffered from radiculopathy, which was one of the six conditions specifically excluded from the provision.

The court reviewed Brien's medical records, which included documentation from several physicians. The court agreed with MetLife's argument that Brien's disability was predominantly caused by neuromusculoskeletal and soft-tissue disorders. None of Brien's other impairments were independently disabling, the court said. According to the court, Brien was eligible for long-term disability benefits due to his neuromusculoskeletal and soft-tissue disorders and MetLife did not abuse its discretion by applying the limitations provision.

The court also disagreed with Brien's argument that objective evidence existed that he suffered from radiculopathy. According to the court, Brien failed to point to any medical opinions that provided objective evidence that he suffered from radiculopathy. Brien's medical records did contain some medical opinions that Brien may have been suffering from radiculopathy, the court said, but those opinions were speculative and radiculopathy was eventually ruled out. The court concluded that substantial evidence supported MetLife's decision that no objective evidence existed regarding radiculopathy.

Brien was represented by Liam P. Curran of Gannon & Hurley, Boston. MetLife was represented by Beth G. Catenza and William D. Pandolph of Sulloway & Hollis, Concord, N.H.


The full text of the opinion is at http://op.bna.com/pen.nsf/r?Open=mmaa-8yfhaq.