The Court Rules

Even sedentary employees may need to take advantage of the disability plan offered by their employers. This fact was brought home again by the case of Bud Minton. A graphics designer for Deloitte and Touche, working long hours at the computer was routine for him. After nine years of this routine, he started to suffer pain in his arms, upper back and neck. He had to take a 10 month leave of absence in 2001 and 2002 after the pain took a turn for the worse.

During his 10-month leave, Minton underwent physical therapy, which allowed him to return to work in July 2001. He carefully managed his pain by spending less time on the computer. But his time on computer was increased four years later when Deloitte and Touche changed his duties at the job. His pain worsened as the hours spent at the computer increased. A month later, he was given an ultimatum by his employer to either move into the position of graphics coordinator or accept a severance package. He requested time off to recover.

The next day, Minton stopped working. In December, 2006 he submitted a claim to Metropolitan Life Insurance Company (MetLife). This company served as the Deloitte and Touche USA LLP Plan (Plan) claims administrator. It also funded the benefits paid to employees under the plan. Along with his claim, Minton attached a statement from his attending physician. The statement declared that he had been diagnosed with fibromyalgia, a medical condition marked by chronic soft tissue and pain, and accompanied frequently in its earlier stages by depression. The physician stated that Minton could work for eight hours per day, but working more than two hours continuously was not possible for him given his condition.

On February 7, 2007, Minton received notice by phone that his claim was going to be denied. On being given additional time to submit his documents by the MetLife representative, he saw the doctor on February 13. In the examination, the doctor found no new objective changes in Minton's condition, and stated the same in an on-page note he sent to MetLife. The doctor also stated in the note that he found that Minton's fibromyalgia seemed to be responding positively to treatment and recommended that Minton not return to work until at least May 15, 2007.

Thereafter, MetLife sent Minton’s file to a board-certified orthopedic surgeon. According to the surgeon "[Minton was not] ... so physically impaired from fibromyalgia that he was unable to do his sedentary job functions which require(s) computer/phone work." He further stated that since Minton's physician had not documented any musculoskeletal abnormality in Minton, the latter had not been impaired since August 2007.

According to him, since Minton's physician had not given a diagnostic cause to his complaints of the pain, and since the doctor was treating Minton with supportive therapies without such a diagnostic having been done, there was insufficient reason to consider Minton physically impaired.

Minton's claim was denied by MetLife on March 12, 2007. The decision contained the following explanation from them, taking the conclusion of the orthopedic surgeon into account: "Although office notes indicate your ongoing complaints of pain, there are no clinical or diagnostic findings that substantiate restrictions and limitations or an impairment of such severity that would prevent you from performing your job."

Minton appealed the decision. Minton's file was then sent to a board-certified rheumatologist, who spoke with Minton's doctor. Despite the fact that Minton's doctor had done an extensive and appropriate workup, a fact that the rheumatologist acknowledged, the latter still concluded that from a rheumatology viewpoint there were no objective findings that justified placing any restrictions or limitations on Minton's activities. To evaluate whether Minton qualified for a psychiatric disability, MetLife also sent Minton's file to a psychiatrist. The psychiatrist's conclusion that Minton's depression was not disabling was not contested by Minton.

Minton requested MetLife send the rheumatologist report to his doctor, which the company did. In the doctor's detailed 11-page report, the doctor gave the history of Minton’s condition, along with its progress and treatment plan. The report noted the "decreased range of motion in his upper back and shoulders" and "tautness in his forearm, shoulder, cervical, and upper back muscles." The doctor acknowledged that the pain reported by Minton seemed out of character with his lack of apparent physical impairments; but, he continued, to a trained physician that Minton's symptoms were proof that he was suffering from chronic soft tissue pain (fibromyalgia). The doctor clarified that no objective tests, for example X-rays, were useful as a diagnostic tool for fibromyalgia.

Minton's doctor also mentioned the treatment strategies he had used for Minton - everything from Vitamin C to Aspirin to Lexapro, nortiptyline, Soma and Cymbalta. "Beyond a limited extent", none of these had helped Minton at all. According to the doctor, spending an 8-hour workday at the computer was still out of question for him, despite these treatment strategies.

The doctor went on to administer a functional capacity test which would provide more information on his condition, and his response to the treatments. Conducted on January 16, 2008 the test consisted of Minton executing a series of assigned tasks for a period of time. He was examined before each task began. After 50 minutes of performing the various tasks, Minton had to stop because of pain. The doctor took a note of increased sensitivity in tender points on his neck, upper back and forearms. He also observed that Minton's muscles in the forearm were stiff, his range of motion had decreased, and the muscles in his upper back and shoulders were swollen. His shoulders were also sloping, the doctor noted. According to the doctor, these changes showed that Minton's use of a computer for sustained periods caused objective changes in his body that proved "that computer use causes functional limitations".

These reports were then sent to the rheumatologist, who praised Minton's doctor for the tests, diagnostic work, and the treatment plan. But his original opinion remained unchanged - that there were no objective findings that supported Minton's claim of disability. According to the rheumatologist, a fibromyalgia patient was never advised to refrain from work because it had never been observed to help a patient, or to worsen the condition. He went on, "The medical literature does not have an answer for this question. Further, if a treatment for fibromyalgia (activity limitation) is not efficacious, then abandonment of that mode of treatment (activity limitation) is the proper course." Overall, he held on to his original opinion.

The letter Minton received from MetLife on February 4, 2008 informed him that his claim was denied based on the rheumatologist’s opinion. He was also informed, once again, that MetLife would not take his own testimony about his inability to perform his duties as evidence in the claim.

Disability Attorney files ERISA Claim Against MetLife

Minton's disability attorney an ERISA claim against the disability plan administrator, MetLife. Since MetLife had discretionary authority to determine Minton's eligibility for benefits, abuse of discretion was the appropriate standard to review MetLife's decision. The Court would also have to consider whether there was a conflict of interest in MetLife being the party that funded the plan as well. If the Court decided that there was a conflict of interest, then the court would decide to what extent it was a factor in the rejection of Minton's claim.

Since Minton had never been told by MetLife what additional material was required of him in support of his claim; and since previous courts had already ruled that such failure was unacceptable, the Court found that "a moderate amount of skepticism "should be used to consider and understand MetLife’s decision.

Disability Attorney Argues That MetLife Abused Its Discretion

The Court considered the history of the claim and MetLife's treatment of it. The record showed that MetLife refused to acknowledge court judgments in this regard - that "fibromyalgia is diagnosed entirely on the basis of a patients' reports of pain and other symptoms," and that "there are no laboratory tests to confirm the diagnosis." (See Benecke v. Barnhart, 2004.) This was despite the fact that Minton’s doctor had reminded the insurance company of this same fact. Minton's doctor had also confirmed, by performing proper tests, that Minton's ability to perform the job was limited because of his fibromyalgia.

Instead of acknowledging the evidence supporting the claim, the company had preferred the opinion of a doctor who sought evidence that could not be obtained for this illness. Just because the doctor may have held the opinion that the pain just wasn't severe enough to practically disable Minton, MetLife was not free to ignore 20 years of court rulings which had said that such an opinion should not be relied on when objective findings are not efficacious in finding a cause of pain. The company had chosen to ignore the wisdom of the Court.

The Court found that MetLife's standard of evidence was such that no one with fibromyalgia or chronic fatigue syndrome could hope to meet it, which denied individuals with these conditions disability benefits that were rightfully theirs. To set such an unreasonable standard, while also discounting Minton's other evidence, was an abuse of MetLife’s discretion.

Court Rules MetLife Wrongfully Denied Long-term Disability Benefits

The Court ruled that MetLife had wrongfully denied Minton's long-term disability benefits. The Court found that Minton was eligible for 24 months of long-term disability benefits under the "own occupation" terms of the Deloitte and Touche USA LLP Plan which began from the start of his disability. The Court ordered MetLife to pay Minton the full amount due for these 24 months plus pre-judgment interest on the unpaid benefits. The Court also found that Minton had the right to file, as a separate motion, for the cost that he had incurred in bringing in this suit.

However, the Court did not find that MetLife had evaluated whether Minton was qualified for benefits under the "any occupation" provisions of his disability insurance plan. The Court allowed (remanded) MetLife to make this decision as it saw fit.

The Court has ruled that Minton's attorney can reopen the case if MetLife decides that he does not qualify under this provision.