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  • Reviewing Physician’s Reliance on Lack of Objective...

    Reviewing Physician’s Reliance on Lack of Objective Evidence an Abuse of Discretion – D. De.
    Attached hereto is a case out of the District of Deleware, Seeman v. Metropolitan Life Insurance Company. In this case, plaintiff seeks ERISA governed long term disability benefits beyond the 24 month “own occupation” period. The case is before the court on the parties’ cross-motions for judgment after a previous remand. Plaintiff’s main disabling conditions are Chronic Fatigue Syndrome and fibromyalgia. In denying plaintiff’s benefits, defendant relied, among other things, on a reviewing physician’s opinion that determined that plaintiff was not disabled because there was a lack of rheumatologic evaluations. The court found that MetLife’s reliance on the opinion was an abuse of discretion because the nature of plaintiff’s conditions are such that they cannot be demonstrated by objective testing.

    Second, the termination letter explains that Dr. Friedman determined that "in the absence of any subsequent rheumatologic evaluations, it is difficult to determine what rheumatologic impairment, if any, currently existed." (D.I. 50-3 at 2745.) The court previously explained that CFS and FMS "cannot be established via objective tests[]" and "it is an abuse of discretion for a plan administrator to demand objective tests establishing the existence of a condition for which there [are] no such tests." (D.I. 32 at 15, n.10)( citing Fisher, 890 F. Supp. 2d at 483). It appears that this is exactly the evidence Dr. Friedman would require to find Seeman disabled. Nevertheless, Seeman provided evidence of CFS and FMS symptoms including pain at "trigger points," fatigue, and the inability to walk, stand, or sit comfortably for an extended period of time. (D.I. 57 at 11, 14.)
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