|
|
|
Decision to Terminate Benefits Upheld because of Principled Decision-Making Process
(October, 2009) By Tamiya N. Wilkes, Associate.
For more information, contact Paul Farquharson.
Charles McDonald v. Metropolitan Life Insurance Company,
Civil No. JFM-08-02063 (D. Md. October 20, 2009)
Charles McDonald ("McDonald"), former Constellation Energy
Group employee, claimed that he was unable to perform his duties as supervisor
of distributions operations, due to tremors in his left arm, which were later
determined to be related to McDonald's emotional state. Specifically, McDonald's
primary care physician found that McDonald's "psychogenic tremors" were evidence
of depression and agitation. McDonald ceased his employment and sought long-term
disability benefits from his employer's long-term disability plan ("the Plan").
Metropolitan Life Insurance Company ("MetLife") was the Plan's Claim
Administrator.
MetLife approved McDonald's long-term disability claim. As
part of the grant of benefits, McDonald was under an ongoing obligation to
continue to provide proof of his disability in order to continue receiving
benefits. McDonald complied with MetLife's requirements and continuously sent
his medical records to MetLife.
MetLife referred McDonald's medical records for review by an
independent physician consultant who determined that McDonald's disability did
not prevent him from performing his job. Thereafter, MetLife terminated
McDonald's receipt of long-term disability benefits. McDonald appealed MetLife's
decision to terminate his benefits. MetLife then referred McDonald's medical
records to two additional independent physician consultants for review; both
consultants determined that McDonald was able to perform his job. None of the
independent consultants ever examined McDonald, but rather based their
assessments on review of his medical records. MetLife upheld its decision to
terminate McDonald's benefits.
McDonald filed suit against MetLife in the United States
District Court for the District of Maryland, pursuant to Section 502(a)(1)(B) of
the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq.
("ERISA"). ERISA provides individuals with a right to bring a civil action
against an insurance company to recover benefits due under the terms of an
insurance plan, to enforce their rights under the terms of a plan, or to clarify
their rights to future benefits under the terms of the plan. 29 U.S.C. §
1132(a)(1)(B). McDonald alleged that MetLife abused its discretion by
terminating his long-term disability benefits without conducting a full and fair
review.
The Plan gave MetLife discretion to construe the terms of
the Plan; therefore, the U.S. District Court for the District of Maryland
reviewed MetLife's decision to terminate McDonald's benefits, under the "abuse
of discretion standard." In other words, MetLife's decision to terminate
McDonald's benefits would only be upheld by the Court if the Court found that
the decision was reasonable.
The Court, in granting MetLife's Motion for Summary
Judgment, held that the record indicated that MetLife's decision to terminate
benefits "resulted from a principled decision-making process." MetLife reviewed
McDonald's records and sought review from three independent consultants.
Although MetLife had initially awarded benefits to McDonald, it was entitled to
continue evaluating his condition after the initial award. The Court further
held that MetLife was not required to adopt the diagnosis of McDonald's primary
care physician over the decision of the independent consultant. "It was not an
abuse of discretion for MetLife to rely on its three consultant physicians'
reports without explicitly explaining its decision to do so."
|
|
|
Top
