Vick v. Metropolitan Life Insur.Co., 2006 U.S.Dist.LEXIS 8722 (E.D.Mich. 2/21/2006)(Issue: Scope of Review).  Plaintiff, a business analyst for EDS, initially commenced a disability leave in 2000 when she developed diabetic complications following a pregnancy, along with a transient ischemic attack.  Her physicians were unable to control her blood sugar level, and she also continued to experience right sided weakness, along with cognitive problems caused by the TIA.  Despite ongoing difficulties, MetLife terminated payments in 2002.  When Vick appealed, the file was reviewed by Dr. Gary Greenhood who concluded that Vick was capable of sitting, standing and walking for 3-4 hours per day without restrictions, although he recommended the claim also be assessed by a psychiatrist.  MetLife then had Dr. Ernest Gosline review the file, who concluded that there was insufficient evidence to show that a psychiatric condition precluded a return to work.  Thus, the denial was upheld.  Shortly thereafter, a new treating physician specializing in diabetic care recommended permanent disability because plaintiff was "unable to safely drive to get to the workplace and she was not safe from serious hypoglycemic episodes occurring while at work." (A.R. 201.) Dr. Franzese concluded that Plaintiff had "developed severe hypoglycemic unawareness, a complication of disabetes. She no longer has the ability to sense when her blood sugars are lowering or low." (A.R. 201.).  Although MetLife initially refused to review the new evidence, after litigation was commenced, the lawsuit was stayed to allow Dr. Greenhood to review the evidence again; however, his opinion remained unchanged, and the lawsuit was then reinstated.

Although the court applied an arbitrary and capricious standard of review, judgment was nonetheless entered for the plaintiff.  The court found that MetLife had improperly relied on an ambiguous statement issued by one of the treating doctors, ignoring that doctor’s ultimate conclusion that a return to work was not feasible until Vick’s blood sugar was controlled.  The court suggested that MetLife’s interpretation of the treating doctor’s report, without seeking clarification from the doctor, was evidence of bias in the administration of the claim along with the bias inherent in the fact that MetLife was both administrator and insurer of benefits. 

The court also demolished MetLife’s argument that its decision could not be found arbitrary and capricious because it was based on the conclusions of two independent physician consultants.  Citing McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 169 (6th Cir. 2003), the court found that even an arbitrary and capricious review has to have “some teeth.”  In evaluating the reviewing doctors’ reports, the court found:

In this case, as in the McDonald case, Defendant's decision to rely on the reports of Dr. Greenhood and Dr. Gosline, rather than Plaintiff's treating physicians was arbitrary and capricious. First, the fact that Defendant relied on the reports of the physicians it hand-selected and paid,  rather than the Plaintiff's personal physicians, is a factor which must be taken into consideration by the court because, under such circumstances, "the potential for self-interested decision-making is evident." See Calvert v. Firstar Finance, Inc., 409 F.3d 286, 292 (6th Cir. 2005) (citation omitted) ("As the plan administrator, [the defendant] had a clear incentive to contract with individuals who were inclined to find in its favor that [the plaintiff] was not entitled to continued LTD benefits."). Moreover, both Dr. Greenhood's and Dr. Gosline's reports contained numerous errors and inherent inconsistencies, which should have been noted by the plan administrator and resulted in less weight being given to them. *25-*26.

In particular, Dr. Greenhood’s report appeared to have been based on a review of an incomplete set of records.  Thus, as the court stated in footnote 6 of its opinion, “Defendant's action in "cherry-picking" and selecting the medical records to send to Dr. Greenhood was arbitrary and capricious. See Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002).:

The court also found that Dr. Greenhood did not fairly assess the report from Dr. Franzese which was provided after the appeal denial.  Turning to Dr. Gosline, the court found his “report is even less reliable than Dr. Greenhood’s report.”  His conclusions as to Vick’s psychiatric treatment were “simply untrue.”  The court also questioned whether he examined all of the psychiatric records since many were unmentioned in his report.  Under Black & Decker v. Nord, 538 U.S. 822 (2003), while there was no requirement to defer to the treating doctors’ findings, the court found that MetLife failed to “credit reliable evidence when choosing to accept” the reviewing doctors’ findings over those of the treating physicians.  *33 (emphasis in original).

The absence of an examination of the plaintiff also troubled the court which cited a Sixth Circuit opinion: 

Thus, while we find that [the defendant's] reliance on a file review does not, standing alone, require the conclusion that [the defendant] acted improperly, we find that the failure to conduct a physical examination--especially where the right to do so is specifically reserved in the plan--may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination. 

Calvert v. Firstar Finance, Inc. 409 F.3d 286, 295 (6th Cir. 2005). *33-*34.  Nor did the court find MetLife’s argument that Vick failed to prove her disability by objective evidence at all persuasive since the blood test readings were clearly objective.  The court was also impressed by the treating doctors’ explanation as to how Vick’s condition functionally limited her work capacity.  In particular, the diabetic specialist explained the mechanism of hypoglycemic unawareness and its impact on plaintiff’s ability to travel safely to work and to work safely while there.  Consequently, the court ruled:

The court finds that Defendant's decision to rely on the reports of Dr. Greenhood and Dr. Gosline, rather than the opinions of all of Plaintiff's treating physicians was arbitrary and capricious. As in Calvert, when the court compares Dr. Greenhood and Dr. Gosline's insufficient file reviews to the thorough objectively verifiable determinations of Plaintiff's treating physicians, and when the court also considers Defendant's conflict of interest, the court concludes that Defendant's decision to deny continuing disability benefits to Plaintiff was arbitrary and capricious. See Calvert, 409 F.3d at 297. In so holding, the court is cognizant that the arbitrary and capricious standard is "extremely deferential and has been described as the least demanding form of judicial review. McDonald, 347 F.3d at 172 (quoting Cozzie v. Metropolitan Life Ins. Co., 140 F.3d 1104, 1107-08 (7th Cir. 1998)). Nonetheless, it is not without "some teeth," id., and this court has

 

an obligation under ERISA to review the administrative record in order to determine whether the plan administrator acted arbitrarily and capriciously in making ERISA benefits determinations. This obligation inherently includes some review of the quality and quantity of the medical evidence and the opinions on both sides of the issues. Otherwise, courts would be rendered to nothing more than rubber stamps for any plan administrator's decision as long as the plan was able to find a single piece of evidence--no matter how obscure or untrustworthy--to support a denial of a claim for ERISA benefits.

 

Id. (citing Hackett v. Xerox Corp. Long-Term Disability Income Plan, 315 F.3d 771, 774-75 (7th Cir.2003)). Here, the court may not simply "rubber stamp" Defendant's decision when the evidence on which it relies is inherently unreliable and untrustworthy as compared to the evidence which supports Plaintiff's claim for continued disability benefits.  *37-*39. 

While reversing the benefit termination, the court nonetheless found for the insurer with respect to its claim that any benefit payment be offset by Social Security disability payments. 

Discussion:      This is an excellent ruling, continuing the trend in the Sixth Circuit to reject benefit denials/terminations when supported solely by reviewing doctor opinions in the face of unequivocal treating doctor reports.  The other key point made in this ruling is the court’s comment on how the treating doctor reports thoroughly explained how the claimant’s medical condition prevented her from working.  Thus, in keeping to the appropriate finding that a diagnosis alone does not equate to disability, and that a conclusory opinion from a treating doctor that someone is disabled will not suffice to challenge an insurer’s rejection of a claim, this court paid heed to the Supreme Court’s Nord ruling’s conclusion that substantial evidence cannot be disregarded without a reasoned explanation.