Announcement

Collapse
No announcement yet.

8th Cir. – Defense Victory

Collapse
X
  • Filter
  • Time
  • Show
Clear All
new posts

  • 8th Cir. – Defense Victory

    Here’s a new case out of the Eighth Circuit, Michelle E. Cooper v. Metropolitan Life Insurance Company. This is a very standard case and really doesn’t have too much interesting in it. The court found that it was proper for the District Court to exclude two doctor affidavits that were proffered at the summary judgment level.

    It was likewise not error, as Cooper contends, for the district court to exclude the affidavits of Drs. Lane and Rathod which she proffered at summary judgment. When an administrator’s benefits determination is reviewed for abuse of discretion, “the scope of review is limited to the evidence that was before the administrator.” Siegel v. Conn. Gen. Life Ins. Co., 702 F.3d 1044, 1049 (8th Cir. 2013). Although this standard may be relaxed where the purpose of admitting the extrinsic evidence is limited to determining the proper standard of review, Waldoch, 757 F.3d at 830, Cooper’s purpose here is to challenge the accuracy of Dr. Schiopu’s report. This is a matter that could have been brought before MetLife in the claims appeal process, and the district court did not abuse its discretion in excluding these affidavits from the record.
    The court further finds that it was not an abuse of discretion for MetLife to rely upon their physicians.

    On review of the record, we find that MetLife’s denial of LTD benefits was not an abuse of discretion. MetLife properly considered all medical records, APS reports, comments, and other information submitted by Cooper and her physicians. On appeal of its initial decision, it consulted a neutral, independent doctor—with the same specialty as Cooper’s attending physician—to review the record and make a recommendation, and gave Cooper’s physicians an opportunity to respond. Although Cooper contends that Dr. Schiopu’s report arbitrarily relied on a lack of objective indicia of disability to the exclusion of subjective indicia, it is generally “not unreasonable for a plan administrator to deny benefits upon a lack of objective evidence.” Pralutsky v. Metro. Life Ins. Co., 435 F.3d 833, 839 (8th Cir. 2006) (quoting McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921, 924-25 (8th Cir. 2004)). This is especially so where, as here, the administrator has consistently specified the type of information sought, and the purpose is to substantiate the extent of the disability, rather than to question the diagnosis. See id.
    However, the one argument which I did find compelling the court does not rule upon. However, the Eighth Circuit does indicate how they would rule if the opinion had been properly before them.

    Finally, Cooper makes much of the fact that a MetLife APNC—not a doctor—determined that her ANA and ERG test results did not need to be forwarded to Dr. Schiopu for her consideration. In particular, she notes that Department of Labor regulations require a claim administrator to “consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment” when “deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment.” 29 C.F.R. § 2560.503-1(h)(3)(iii). Because MetLife allowed a nurse with unspecified training to decide the medical importance of her lab tests, Cooper argues it violated these regulations. In her view, this procedural failure warrants remand to the Plan or even outright reversal.

    Arguably, we need not decide this issue, as the record suggests that Cooper did not raise this theory before the district court. In any event, even if Cooper is correct in her application of the regulation—an issue we decline to reach here—MetLife’s error would not warrant the relief she suggests because it was harmless. As our sister circuits have recognized, the proper inquiry in analyzing a claim administrator’s compliance with § 2560.503-1 is “substantial compliance,” rather than “technical compliance.” See Grasso Enters., LLC v. Express Scripts, Inc., 809 F.3d 1033, 1038 (8th Cir. 2016) (citing Lafleur v. La. Health Serv. & Indem. Co., 563 F.3d 148, 154 (5th Cir. 2009)). “While we have not expressly adopted this substantial compliance standard, we have applied a substantively equivalent standard, evaluating whether a plan’s entire claim denial process provided the claimant ‘a full and fair review of her claim.’” Id. (quoting Midgett v. Wash. Grp. Int’l Long Term Disability Plan, 561 F.3d 887, 896 (8th Cir. 2009)). Here, Cooper presents no evidence to suggest that review of her ANA and ERG test results by a doctor would have altered MetLife’s conclusion that she was not disabled for purposes of the Plan. Indeed, the record reflects that the APNC correctly determined that the ANA result merely confirmed a diagnosis of lupus—which Dr. Schiopu had already accepted—and that the ERG had shown only mild rod and cone dysfunction that was inconsistent with Plaquenil retinopathy. Nothing in the record shows that these findings would have altered the Plan’s determination of no disability, or that Cooper was denied a “full and fair” review of her claim.
    I am not certain, obviously, without seeing the record itself, that I agree with the court’s determination here. The court believes that these objective medical tests could not have altered the reviewing physician’s opinion. However, I’m not certain that the court should stand in that position and I would argue that we cannot guess what would have influenced or not influenced a reviewing physician’s opinion. Either way, the opinion is attached below.
    Attached Files

  • #2
    Nathan, thanks for posting. Glad your back up and running.

    Comment

    Working...
    X