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Failure to Consider Whether Claimant Met Diagnostic Criteria...

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  • Failure to Consider Whether Claimant Met Diagnostic Criteria...

    Failure to Consider Whether Claimant Met Diagnostic Criteria of Condition Excluded From 24 Month Cap an Abuse of Discretion – W.D.Mi.

    Attached is a case out of the Western District of Michigan, Hills v. Metropolitan Life Insurance Company. In this case, plaintiff seeks benefits beyond the 24 month “mental/nervous” cap. Plaintiff suffers from Schizoaffective Disorder which is a combination of the symptoms of Schizophrenia and a mood disorder. Defendant paid plaintiff 24 months under the “mental/nervous” limitation of the policy and subsequently denied her claim asserting that she did not suffer from Schizophrenia, which was excluded from the limitation. Plaintiff appealed, exhausted administrative remedies, and filed suit asserting that her diagnosis of Schizoaffective Disorder qualified her for the exclusion because the diagnosis was “Schizophrenia plus.” The court found that MetLife abused its discretion in not considering whether the symptoms from Schizoaffective Disorder met the diagnostic criteria for Schizophrenia.

    MetLife has not considered whether Hills’s symptoms meet the diagnostic criteria for Schizophrenia. The manner in which Dr. Goldman worded the conclusions in his addendum, and the manner in which MetLife worded its final denial, were artful. Both avoided directly addressing whether Hills’s symptoms met the diagnostic criteria for Schizophrenia. The diagnosis of Schizoaffective Disorder does not require the conclusion that Hills cannot be schizophrenic. And, if her symptoms meet the diagnostic criteria for Schizophrenia, then she would qualify for the exclusion, even of a Schizophrenia plus diagnosis would be medically proper.

    The Court notes that MetLife made this same distinction in another disability benefits case involving the same policy language, and the court reached the same conclusion, although for slightly different reasons. See Duncan v. Metro. Life Ins. Co., No. 2:15-cv-626, 2016 WL 6651317 (D. Utah, Nov. 10, 2016). Duncan, also an employee of Verizon, was diagnosed with Schizoaffective Disorder. Id. at *2. MetLife terminated benefits after two years “solely in its interpretation that the schizophrenia exclusion does not include schizoaffective disorder.” Id. In its letter denying the appeal, MetLife explained that the “’disabling diagnosis was schizoaffective disorder, which would not support a diagnosis of schizophrenia,’ and that ‘schizoaffective disorder [is] a separate diagnosis from schizophrenia with its own diagnostic criteria.’” Id. at *5 (alteration in original).

    In Duncan, the court provided several reasons for its conclusion that the plan administrator’s decision was wrong, only three of which will be briefly discuss here. First,the court concluded that the word “schizophrenia” in the plan language was ambiguous.4 In that case, Duncan submitted evidence from medical sources and from judicial opinions showing that the term is used to reference both a specific disorder as well as a spectrum of disorders, including Schizoaffective Disorder. Id. at *6. Second, the court examined the DSM-V and concluded, as this Court did, that a proper diagnosis of Schizoaffective Disorder does not preclude the presence of Schizophrenia.

    While the features and symptoms of the two disorders may co-exist, the diagnoses never do. The DSM makes clear that when all criteria of both disorders are present, only a diagnosis of schizoaffective disorder should be given. As a result, MetLife’s reliance on the name of the diagnosis and the diagnostic criteria in the abstract---without attempting to determine whether an individual could actually satisfy the diagnostic criteria for schizophrenia---is an arbitrary and capricious way of defining the scope of the exclusion.

    Id. at *7. Third, the court noted that most of the plan exclusions, including schizophrenia and dementia, used “umbrella terms that compassed many diagnoses.” Id. at *7. The court reasoned, because the plan’s exclusions used broad terms which focused on features or criteria, rather than specific diagnoses, a decision that did not consider whether the beneficiary satisfied the criteria for an exclusion would be arbitrary and capricious.
    The court remanded the case back to MetLife for analysis regarding whether plaintiff’s symptoms met the requirements for a diagnosis of Schizophrenia.
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