Thomas Judge v. Metropolitan Life Insurance Co.

710 F.3d 651, 55 Employee Benefits Cas. (BNA) 1513, 2013 WL 1188067, 2013 U.S. App. LEXIS 5840
CourtCourt of Appeals for the Sixth Circuit
DecidedMarch 25, 2013
Docket12-1092
StatusPublished
Cited by73 cases

This text of 710 F.3d 651 (Thomas Judge v. Metropolitan Life Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Thomas Judge v. Metropolitan Life Insurance Co., 710 F.3d 651, 55 Employee Benefits Cas. (BNA) 1513, 2013 WL 1188067, 2013 U.S. App. LEXIS 5840 (6th Cir. 2013).

Opinions

GILMAN, J., delivered the opinion of the court, in which KETHLEDGE, J., joined, and MOORE, J., joined in part. MOORE, J. (pp. 664-67), delivered a separate opinion dissenting in part.

OPINION

RONALD LEE GILMAN, Circuit Judge.

Thomas Judge, who underwent surgery to repair an aortic valve and a dilated ascending aorta, applied for disability benefits under a group insurance policy (the Plan) issued by Metropolitan Life Insurance Company (MetLife). MetLife denied benefits, however, when it determined that Judge was not totally and permanently disabled under the terms of the Plan. After exhausting MetLife’s internal administrative procedures, Judge brought this action to recover benefits pursuant to 29 U.S.C. § 1132(a)(1)(B), a provision of the Employee Retirement Income Security Act (ERISA). The district court granted judgment on the administrative record in favor of MetLife.

Judge argues on appeal that MetLife’s denial of benefits was arbitrary and capricious. Specifically, he contends that (1) MetLife applied the wrong definition of “total disability” to Judge’s claim, (2) Met-Life erred in failing to obtain vocational evidence before concluding that Judge was not totally and permanently disabled, (3) MetLife erred in conducting a file review by a nurse in lieu of having Judge undergo an independent medical examination, and (4) there was a conflict of interest because MetLife both evaluates claims and pays benefits under the Plan. For the reasons set forth below, we AFFIRM the judgment of the district court.

I. BACKGROUND

Judge, who has a high-school education, worked as an airline baggage handler and ramp agent for 20 years. As an employee of Delta Airlines, he was covered by Delta’s term life insurance policy. The insurance policy provides for the early payment of benefits of up to $100,000 if an employee becomes totally and permanently disabled. MetLife is both the Plan’s administrator and the payor of benefits. The Plan defines total and permanent disability as follows:

Total and Permanent Disability or Totally and Permanently Disabled means, for purposes of this section, that because of a sickness or an injury ...:
You are expected never again to be able to do:
Your job; and
Any other job for which You are fit by education, training or experience.

In order to claim benefits under the Plan, Judge was required to send MetLife proof that he was totally and permanently disabled and that such total and permanent disability has continued without interruption. The Plan defines “proof’ as follows:

Proof means written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When any claim is made for any benefit described in this certificate, Proof must establish: the nature and extent of the loss or condition; Our obligation to pay [655]*655the claim; and the claimant’s right to receive payment.

After his brother was diagnosed with an ascending aortic aneurysm, Judge saw his own physician and learned that he had a similar problem with a dilated ascending aorta. Cardiac surgeon C. Michael Deeb recommended surgery to replace the ascending aorta and remove a mass on Judge’s aortic valve. Judge underwent surgery in March 2010 and has not returned to work with Delta since. He was 47 years old at the time of the surgery. In November of 2010, Judge filed a claim with MetLife for a lump-sum disability benefit.

Judge submitted several post-surgery reports from his physicians in support of his claim. These physicians included Dr. Deeb, Dr. Himanshu J. Patel (who worked with Dr. Deeb), and Dr. Daniel Harber, another of Judge’s treating physicians. MetLife considered each of these reports in evaluating Judge’s claim.

Dr. Deeb examined Judge in April 2010. In a letter addressed to Dr. Harber and Dr. Corinne Adler (still another of Judge’s treating physicians), Dr. Deeb noted that Judge was “actually doing well.” Judge was “awake, alert, oriented, and neurologically intact.” In addition, Judge was “up and about, freely mobile.” Dr. Deeb advised that Judge could “increase his activity,” but limited him to lifting no more than 15 pounds. These assessments were supported in extensive medical detail.

Judge saw Dr. Patel in July 2010. Dr. Patel noted in a letter to Drs. Harber and Adler that Judge was “alert and oriented and in no acute distress.” He also wrote that a CT scan of Judge’s chest and abdomen showed “an intact repair of his ascending aorta with no evidence of complication.” Because Judge had “an intact aortic repair with a repaired bicuspid aortic valve,” Dr. Patel advised that Judge could “gradually increase his lifting, pushing, and pulling to [a] maximum of 50 pounds” and could “participate in mild-to-moderate intensity level aerobic activities.” Dr. Patel cautioned that Judge required “an additional six weeks’ time off work to complete his physical therapy.” These assessments, too, were accompanied by an extensive discussion of Judge’s medical condition.

In October 2010, Dr. Deeb completed an “Attending Physician Statement.” Dr. Deeb filled in boxes on the form that, without explanation, restricted Judge to two hours of intermittent sitting and zero hours of standing or walking per day. Another box was checked that restricted Judge from reaching above shoulder level, climbing, twisting, bending, or stooping. He was, however, permitted to operate a motor vehicle. In response to the question: “In your opinion, why is patient unable to perform job duties?”, Dr. Deeb wrote: “Lifting restriction 30 to 35 lbs.” But the report also stated that Judge could work eight hours per day and that only his lifting restriction was unlikely to improve. With respect to Judge’s cardiac capacity, Dr. Deeb checked the box for “Class 2 (Slight Limitation).” Judge concedes that Dr. Deeb “noted that Mr. Judge was totally disabled for [only] an indefinite period of time.” There is no further medical explanation contained in or attached to Dr. Deeb’s statement.

In December 2010, Dr. Harber completed his own Attending Physician Statement. Dr. Harber also filled in boxes that restricted Judge to two hours of intermittent sitting and zero hours of standing or walking per day. He similarly stated that Judge could not reach above shoulder level, climb, twist, bend, or stoop, but that he could operate a motor vehicle. Dr. Harber indicated that Judge was unable to perform his job duties because he was not to lift anything over 30 pounds. But he stated that Judge could work eight hours per [656]*656day and that “[a]ll areas should improve besides [sic] lifting restrictions.” Dr. Harber also classified Judge’s cardiac capacity as “Class 2 (Slight Limitation).” In response to the question: “Have you advised patient to return to work?” Dr. Harber checked the box for “No,” and in response to the next prompt: “Any work/activity restrictions applicable,” he wrote that he was “basing this on Dr. Deeb’s recommendation.” There is no further medical explanation contained in or attached to Dr. Harber’s statement.

A nurse consultant at MetLife, Janice Kinsinger, reviewed the medical reports provided by Judge’s physicians. In her evaluation, she noted the inconsistencies between the first two reports (Dr. Deeb’s April 2010 letter and Dr.

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Cite This Page — Counsel Stack

Bluebook (online)
710 F.3d 651, 55 Employee Benefits Cas. (BNA) 1513, 2013 WL 1188067, 2013 U.S. App. LEXIS 5840, Counsel Stack Legal Research, https://law.counselstack.com/opinion/thomas-judge-v-metropolitan-life-insurance-co-ca6-2013.