ERISA Long Term Disability Case Citations and references

DISCLAIMER: Please note that every case is different and these verdicts and settlements, while accurate, do not represent what we may obtain for you in your case.

MetLife Abused Discretion in Chronic Pain Case--Benefit Paid

In this chronic, severe pain ERISA disability case, the court holds that MetLife abused it discretion and the claimant is entitled to benefits.                

(as always, do your own research!)

   United States Court of Appeals, Fourth Circuit.

                        Janet R. GORSKI, Plaintiff-Appellant,

                                         v.

  ITT LONG TERM DISABILITY PLAN FOR SALARIED EMPLOYEES; Metropolitan Life Insurance
                           Company, Defendants-Appellees.

                                    No. 07-1063.


                               Argued Sept. 24, 2008.

                                Decided Nov. 3, 2008.


Appeal from the United States District Court for the Eastern District of North
Carolina, at Greenville. James C. Dever III, District Judge. (7:05-cv-00150-D).


ARGUED:Andrew O. Whiteman, Hartzell & Whiteman, L.L.P., Raleigh, North Carolina,
for Appellant. Theresa Jeszeck Baker, Metlife, Long Island City, New York, for
Appellees. ON BRIEF:Stephen A. Dunn, Emanuel & Dunn, P.L.L.C., Raleigh, North
Carolina, for Appellees.


Before MICHAEL and TRAXLER, Circuit Judges, and RICHARD L. VOORHEES, United States
District Judge for the Western District of North Carolina, sitting by designation.


Reversed and remanded by unpublished PER CURIAM opinion. Judge Traxler wrote an
opinion concurring in part and dissenting in part.

Unpublished opinions are not binding precedent in this circuit.PER CURIAM:

*1 Janet R. Gorski appeals a district court order denying her motion for summary
judgment and granting summary judgment against her in her action against the ITT
Long Term Disability ("LTD") Plan for Salaried Employees ("the Plan") and
Metropolitan Life Insurance Company ("MetLife"), alleging wrongful termination of
her LTD benefits. We reverse and remand to the district court with instructions to
reinstate Gorski's benefit award and consider her claims for prejudgment interest
and an award of attorney's fees and costs.

                                         I.

 Gorski worked as a secretary at ITT Automotive in Auburn Hills, Michigan, until
February 1998. While at ITT, she participated in the Plan, which provides LTD
benefits. MetLife insures the Plan and serves as claims administrator with
"discretionary authority to interpret the terms of the Plan and to determine
eligibility for and entitlement to Plan benefits in accordance with the terms of
the Plan."J.A. 500. To qualify for LTD benefits, participants must be "Totally
Disabled," which the Plan defines as follows:


 1) During the six-month qualifying period plus the first 12 months in which you
 receive LTD benefits, you are considered Totally Disabled if you are unable to
 perform the regular duties of your occupation while under the continuous and
 appropriate care of a licensed physician and you are not employed elsewhere.


 2) After the first 12 months in which you receive LTD benefits, Total Disability
 means you are unable to engage in any and every duty pertaining to any
 occupation or employment for wage or profit for which you are qualified, or
 become reasonably qualified by training, education or experience.


J.A. 490. In order to continue to receive LTD benefits under the Plan,
participants must regularly submit proof of continued disability.


In October 1997, Gorski received treatment from Dr. Young Seo for "severe lower
back pain" that she reported as resulting from lifting her leg as she tried to put
on her pants. J.A. 79. She claims this injury was a reaggravation of a previous
injury that happened in early 1977 when she fell outside of ITT. Dr. Seo diagnosed
Gorski as having L5 nerve root irritation, a bulging disc, and inflammation of the
joint between L4 and L5, and he treated her with spinal injections. Gorski missed
approximately one month of work, then returned to work for approximately nine
weeks before suffering a recurrence of her symptoms on February 6, 1998. An MRI
dated that day showed two herniated discs. As a result, she received special
injections, pain medication, and physical therapy. She did not return to work
again.


 Gorski applied for LTD benefits on August 11, 1998. Dr. George R. Shell, a
neurosurgeon, stated in an Attending Physician Statement ("APS") that Gorski had
two herniated discs and was scheduled for "lumbar cage fusion" surgery on August
18, 1998, which would render her "unable to perform any type of work for at least
6 months."J.A. 133-34. Shortly thereafter, MetLife approved Gorski's claim, as of
August 11, 1998.


*2 Nearly two months after the surgery, Gorski informed MetLife that she was
experiencing "[n]umb feet, legs & low back nerve spasms [with] shooting pain down
both legs" and that she could not lift more than two pounds, sit for more than 30
minutes, or walk for a very long time without "excessive pain" in her legs and
lower back. J.A. 136. Dr. Schell reported that Gorski had been doing very well
until December 1998, when during a bout with vomiting, she "felt something pop in
her back" and began having pain in her right leg and back. J.A. 310. On March 19,
1999, Dr. Schell noted that Gorski "still seems quite symptomatic." J.A. 177. In
that regard, Gorski reported that although her legs were feeling better, she had
burning pain in her hips when she walked and discomfort when she sat as well.
Gorski underwent an MRI examination on June 22, 1999.


Meanwhile, Dr. Schell had provided MetLife in May 1999 with his office notes,
discharge records relating to the August 1998 surgery, and radiological reports.
This prompted MetLife, on July 27, 1999, to approve a continuance of Gorski's LTD
benefits on the basis that she was unable to perform any occupation for which she
was qualified. Dr. Schell treated Gorski with epidural injections and physical
therapy until she moved to North Carolina in December 1999.


In September 1999, MetLife arranged for an independent medical examination of
Gorski by Dr. Robert S. Levine, an orthopedic surgeon. After examining Gorski and
reviewing her medical records, Dr. Levine diagnosed "status post laminectomy and
anterior fusion (cages) for ruptured disc" and "chronic pain syndrome with
significant depression."J.A. 212. He recommended that Gorski receive treatment at
a multidisciplinary pain center offering pain management, that she participate in
a functional reactivation program, and that she receive psychological therapy. He
determined that Gorski should be capable of performing sedentary activities that
involve no bending and do not require her to lift more than five pounds. He
believed that she could have a functional capacities evaluation and noted that he
"felt that there are significant ongoing psychological factors which would
interfere with her ability to perform and to return to gainful employment."J.A.
212. Responding to Dr. Levine's opinion, Dr. Schell informed MetLife that while he
did not reject Dr. Levine's treatment recommendations, he believed that Gorski
might also need further surgery sometime in the future.


When Gorski subsequently moved to North Carolina, she began receiving treatment
from Dr. George Huffmon, a neurosurgeon. On June 15, 2000, Gorski underwent a CT
scan, flexion/extension scan, and bone scan. Reviewing the results, Dr. Huffmon
concluded that Gorski's"4/5 right cage is kicked out laterally" and seemed to be
compressing at least one nerve root and possibly two. J.A. 348. He recommended
physical therapy and surgery to have "pedicle screws from 4 to S1 and attempt to
get the cage out if we can't clamp it down and put it back in position."J.A. 348.
He noted, though, that Gorski was "very reluctant" to undergo another surgery.
J.A. 347. After examining Gorski again on December 28, 2000, Dr. Huffmon concluded
that her pain was still preventing her from returning to work. He sent her for a
second opinion regarding possible surgery to Dr. Mark Rodger, who determined that
she was not a good candidate for surgery and turned her care over to a primary
care physician and pain management specialist.

*3 On May 25, 2001, MetLife asked Gorski for additional information concerning her
treatment. Gorski wrote that she suffered from "spas [ ] ming in [her] low [er]
back, shooting pain into [her] right leg, [a] numb right foot, [and] stinging pain
in [her] toes."J.A. 259. She also reported that her right leg was weak, she could
not lift it very much, and that it would give out, causing her to fall if she did
not have someone or something to support her. She noted that, since her surgery,
she had been depressed and suffered irritable bowel syndrome, increased
occurrences of dizziness, and urinary incontinence. She also wrote that no
accommodation would allow her to return to work because she could not "even clean
[her] house or lift groceries" and that even "holding a full gallon of milk is a
chore."J.A. 261. She stated that she "ha [s] to lay down in a fetal position to
take the pressure off ... when [she] stand[s] for 20-25 min[utes,] sometimes even
less."J.A. 261. She stated that she could not "believe how everything has a tie to
[her] lower back."J.A. 261 (emphasis in original).

As part of its ongoing review, MetLife also conducted videotape surveillance of
Gorski. MetLife's investigator filmed Gorski on August 28, 2001, leaving her home,
driving to a grocery store, and shopping with another female and child without
visible medical aides or devices, before driving home. Gorski's gait appeared
normal, and she did not appear to be in pain. On October 9, 2001, he observed her
watering plants in her front yard, which included her carrying gallon jugs of
water in each hand and bending at the knees and at the waist to pour water from
the jugs, again without any apparent pain or difficulty.

MetLife also reviewed an APS from Dr. Huffmon, dated August 2, 2001, diagnosing
"L4-5 radiculopathy, post laminectomy syndrome" and again indicating his view that
treatment should include "fusion [with] pedicle screws." J.A. 268. Dr. Huffmon
concluded that Gorski was "[u]nimproved" and disabled for any occupation. J.A.
269. He listed restrictions for all activities except grasping, handling, finger
dexterity, and concentrated visual attention.

Dr. William J. Faircloth also completed an APS form in January 2002. Like Dr.
Huffmon, he concluded that Gorski'snerve root compression, resulting in lower back
pain, right leg pain, and numbness, rendered her disabled for any occupation. He
noted that even her sitting ability was limited.

On April 16, 2002, MetLife sought clarification from Dr. Faircloth regarding his
conclusion that Gorski's ability to sit was limited, asking in particular whether
Gorski could "sit for 45 minutes, break, and resume sitting for another 45
minutes, through[ ]out an 8 hour work day" and, if she could not, to specify her
sitting capability. J.A. 408. Dr. Faircloth responded that he was unable to make
that determination. When MetLife asked for clarification, Dr. Faircloth's office
responded that he could not answer the questions because he had not seen Gorski
often enough. At his most recent examination of her, on February 13, 2002, he had
noted that she was exercising regularly and had no new or specific complaints.


*4 MetLife subsequently informed Gorski, via a letter dated June 4, 2002, that it
was terminating her benefits as of that date since she was no longer disabled
within the meaning of the Plan. The letter referenced Dr. Faircloth's inability to
determine the extent of her sitting limitations, the fact that she was regularly
exercising on February 13, 2002, and the investigator's surveillance report. It
also noted her vocational history, including her associate degree in business
administration and her strong background in administrative, secretarial, and
bookkeeping jobs. Considering the skills needed to be an administrative assistant
and that the job is "sedentary and require[s] lifting, carrying, pushing and
pulling of [only] 10 pounds occasionally," J.A. 288, MetLife concluded that Gorski
could perform her prior job. The letter recommended that if Gorski appealed the
decision, she should provide recent physical exam findings, recent diagnostic
testing results, her current treatment plan and response, restrictions and
limitations preventing her from working, her prognosis for when she could return
to work, and any other information or documentation that would support a finding
of disability.

 Gorski appealed her benefits termination on September 19, 2002, submitting
additional medical records, including, among other things, office notes of an
outpatient consultation in July 2000 with neurosurgeon Thomas Melin, who noted
that "the L4/5 cage on the right appears to be somewhat laterally displaced and
posteriorly displaced."J.A. 306. On December 4, 2002, Gorski sent MetLife a note
from Dr. Huffmon stating that Gorski"can sit for 45 minutes and take a 10 minute
break to lay down [and] then resume sitting for up to 4 hours a day-there is No
Job this woman can perform."J.A. 408 (emphasis in original). Gorski also sent
MetLife notes from Dr. Richard Leighton regarding his examination of her on August
8, 2002. He wrote that "[m]anual motor strength testing showed some weakness of
the plantar flexors and dorsiflexors on the right which are 4/5. She has point
tenderness over the trochanteric bursa on the left but has reasonable fluid
ROM."J.A. 409. He also reported that x-rays showed "a bit of posterior
displacement of one of the cages."J.A. 409. He noted, concerning her history, that
she had "numbness, weakness, prior fractures, back pain, ringing in her ears,
blood in her stool, lumps, balance problems, depression, sleep disorder, and easy
bruising."J.A. 411. He added that Gorski walks with a cane and has "[p]ain [that]
comes and goes."J.A. 411. He described her as "[w]alk[ing] with an antalgic gait
and slightly off balance."J.A. 411.

MetLife subsequently referred Gorski's file on December 23, 2002, to Network
Medical Review for an independent physician consultation review. Dr. M. Marc
Soriano reported conducting a "thorough review" of the medical records MetLife had
provided him. J.A. 426. He specifically discussed the September 13, 1999,
examination performed by Dr. Levine and the notes from Dr. Leighton's August 8,
2002, examination, stating about them that Gorski's"subjective complaints have
remained significant despite the fact that the objective exams are
unremarkable."J.A. 426. Dr. Soriano concluded that Gorski's"examinations are all
replete with subjective complaints but no significant objective findings ... that
would support an impairment," J.A. 426, and that Dr. Huffmon's opinion that Gorski
could sit for only 45 minutes an hour for four hours per day was "not
substantiated in the clinical documentation," J.A. 427. Dr. Soriano determined
from his review that Gorski could sit, stand, or walk continuously for one hour
and could sit, stand, and walk for all eight hours of an eight-hour period. In
light of Gorski's prior surgery and her continuing complaints of pain, Dr. Soriano
concluded that Gorski"should be limited to sedentary to light duty positions."J.A.
427. He finally stated that " Gorski's complaints remain only subjective and are
disproportionate to any objective findings on x-rays or physical exam
findings."J.A. 427. Dr. Soriano's report made no mention of the dislodged surgical
hardware that several of the other doctors concluded was irritating her
surrounding nerve tissue and causing her to suffer significant pain in her lower
back and right leg.

*5 MetLife sent Gorski's attorney a letter dated January 20, 2003, stating that it
had denied Gorski's appeal. The letter, relying on the Plan, Gorski's job
description, the limitations that Dr. Huffmon and Dr. Faircloth had identified,
and Dr. Soriano's report, concluded that "the medical documentation in [MetLife's]
file does not support a disability, as defined in the plan."J.A. 421.

 Gorski then initiated the current action in federal court on August 12, 2005,
under 29 U.S.C.A. s 1132(a)(1)(B) (West 1999) of the Employee Retirement Income
Security Act of 1974 ("ERISA"), for wrongful denial of benefits. She requested LTD
benefits from June 4, 2002 to the judgment date, prejudgment interest, a
determination that she is entitled to continue to receive benefits for as long as
she remains eligible, and attorney's fees and costs.

Considering cross-motions for summary judgment, the district court denied Gorski's
motion and granted MetLife's motion. The court applied a modified
abuse-of-discretion standard of review to MetLife's decision in light of MetLife's
status as both the insurer of LTD benefits and the fiduciary with discretionary
authority to determine benefits eligibility. The court concluded that despite the
conclusions of Drs. Huffmon and Faircloth that Gorski could not return to work,
MetLife's decision to uphold its benefits denial was reasonable as a matter of
law. The court pointed out that Dr. Faircloth could not say that Gorski could not
work throughout an eight-hour day, sitting 45 minutes at an interval with breaks
in between, and that Dr. Huffmon did not explain his view that Gorski could sit
only in 45-minute increments for a total of four hours. The court also recognized
that although Gorski's doctors identified objective evidence indicating Gorski
would suffer chronic lower back pain, in the end, their opinions that she could
not do her old job depended on the veracity of Gorski's self-reported limitations.
The court noted that independent physician consultant Dr. Levine concluded that
Gorski could engage in sedentary activities following pain management therapy, and
that Dr. Soriano concurred in that assessment. The district court finally added
that the video surveillance reasonably could be viewed as further evidence that
Gorski's limitations were not as great as Drs. Huffmon and Faircloth believed.


                                         II.


                                         A.


We review the grant of summary judgment de novo, viewing all of the facts in the
light most favorable to the nonmovant. See  EEOC v. Navy Fed. Credit Union, 424
F.3d 397, 405 (4th Cir.2005). Summary judgment is appropriate when "the pleadings,
depositions, answers to interrogatories, and admissions on file, together with the
affidavits, if any, show that there is no genuine issue as to any material fact
and that the moving party is entitled to a judgment as a matter of
law."Fed.R.Civ.P. 56(c); see  Celotex Corp. v. Catrett, 477 U.S. 317, 322-23
(1986).

In reviewing the denial of benefits under an ERISA plan, a district court's first
task is to consider de novo whether the relevant plan documents confer
discretionary authority on the plan administrator to make a benefits-eligibility
determination. See  Johannssen v. District No. 1-Pacific Coast Dist., MEBA Pen.
Plan, 292 F.3d 159, 168 (4th Cir.2002)."When a plan by its terms confers
discretion on the plan's administrator to interpret its provisions and the
administrator acts reasonably within the scope of that discretion, courts defer to
the administrator's interpretation." Colucci v. Agfa Corp. Severance Pay Plan, 431
F.3d 170, 176 (4th Cir.2005). The parties agree that the Plan confers
discretionary authority upon MetLife, as the plan administrator, to make benefit
decisions according to the terms of the plan. Under the abuse-of-discretion
standard, the reviewing court will not disturb the plan administrator's decision
as long as it was reasonable. Such a decision is reasonable "if it is the result
of a deliberate, principled reasoning process and if it is supported by
substantial evidence," Stup v. UNUM Life Ins. Co. of Am., 390 F .3d 301, 307 (4th
Cir.2004) (internal quotation marks omitted), which is "evidence which a reasoning
mind would accept as sufficient to support a particular conclusion," LeFebre v.
Westinghouse Elec. Corp., 747 F.2d 197, 208 (4th Cir.1984) (internal quotation
marks omitted).

*6 However, when the plan administrator's own business interests will be directly
affected by its decision regarding the benefits claim, a conflict of interest
arises that "may operate to reduce the deference given to a discretionary decision
of that fiduciary to the extent necessary to neutralize any untoward influence
resulting from that conflict." Blackshear v. Reliance Standard Life Ins. Co., 509
F.3d 634, 639 (4th Cir.2007) (internal quotation marks & alteration omitted). In
effect, we use a "sliding-scale standard of review" when a genuine conflict
exists: " '[t]he more incentive for the administrator ... to benefit itself by a
certain interpretation of benefit eligibility ..., the more objectively reasonable
the administrator['s] ... decision must be and the more substantial the evidence
must be to support it.'"  Stup, 390 F.3d at 307 (quoting  Ellis v. Metro. Life
Ins. Co., 126 F.3d 228, 233 (4th Cir.1997)); see also  Metro. Life Ins. Co. v.
Glenn, 128 S.Ct. 2343, 2350 (2008) (explaining that when plan administrator both
evaluates benefits claims and pays those claims, the resulting conflict of
interest "should be weighed as a factor in determining whether there is an abuse
of discretion" (internal quotation marks omitted)).

Because MetLife insures the very plan it administers, the district court concluded
that MetLife was operating under a conflict of interest. MetLife does not
challenge the district court's application of the modified abuse-of-discretion
standard under the circumstances, and we agree that this standard of review was
appropriate. See  Stup, 390 F.3d at 307.

                                         B.

With these principles in mind, we turn to the substantive questions. The issue
decided by MetLife and litigated before the district court was whether Gorski
could "perform the sedentary duties of an administrative assistant."J.A. 513.
Resolution of this question became dependent on the legitimacy and extent of
Gorski's back pain. In this regard, Gorski has produced evidence clearly
demonstrating that dislodged surgical hardware was irritating nerve tissue
surrounding the hardware, causing her substantial pain and other problems as well.
On that point, Gorski produced the report of Dr. Huffmon that a CT scan and
flexion and extension films showed that her 4/5 cage was "kicked out laterally,"
apparently "compressing her right 4 nerve root and maybe even catching her right 5
nerve root as well," resulting in "[l]ow back pain and right leg pain."J.A. 348.
Gorski presented an APS from Dr. Faircloth essentially agreeing with Dr. Huffmon's
assessment. Dr. Leighton further noted that Gorski's x-rays showed "a bit of
posterior displacement of one of the cages."J.A. 409. Drs. Huffmon and Faircloth
both concluded that Gorski was disabled from any occupation, and Dr. Faircloth
specifically opined that Gorski"can sit for 45 minutes and take a 10 minute break
to lay down [and] then resume sitting for up to 4 hours a day."J.A. 408. Gorski
herself represented that no accommodation could allow her to return to the
workplace in light of the severity of her lower back pain. Thus, Gorski clearly
satisfied her initial burden of producing substantial evidence that she was
disabled from performing any job.

*7 In nonetheless upholding its termination of Gorski's disability benefits,
MetLife noted that Gorski's job description for her previous job as sales
secretary required her "to sit for 3-4 hours, stand, walk, and climb for 1-2 hours
per work shift."J.A. 420. The job also "required some repetitive use of the hands
and the use of the neck and head" but only "occasional lifting or carrying up to
10 lbs." J.A. 420. MetLife concluded that while Drs. Faircloth and Huffmon opined
that Gorski could not perform any job, the specific limitations that the doctors
identified regarding her functionality did not preclude her working in her prior
job as an administrative assistant. MetLife also relied on Dr. Soriano's
conclusions that " Gorski did not have any impairment based upon objective
findings," that she could perform sedentary work, and that Dr. Huffmon's sitting
restrictions of 45 minutes on, followed by 10-minute breaks, for up to 45 minutes
were not supported by Gorski's recent physical examinations. J.A. 421.

 Gorski argues that MetLife acted unreasonably in basing its final decision to
terminate her benefits on Dr. Soriano's opinion. MetLife does not deny that it
relied on Dr. Soriano's opinion, but maintains that its reliance was reasonable.
We agree with Gorski.

The crux of Dr. Soriano's opinion is that there are no objective findings to
support Gorski's complaints of pain and that Gorski exaggerates the level of pain.
Indeed, as noted, Dr. Soriano went so far as to say that Gorski"does not have any
impairment based upon objective findings."J.A. 426 (emphasis added); see J.A. 427
("[S]he has no obvious objective impairment").

The problem with Dr. Soriano's opinion is that Dr. Soriano never explained on what
basis he doubted the veracity of Gorski, whom he had never examined. To the extent
that he did not believe that Gorski's physical problems would cause the intense
pain of which she complained, he never revealed why he rejected the view of the
other doctors that dislodged surgical hardware was irritating surrounding nerve
tissue, resulting in debilitating pain for Gorski. In fact, he never discussed at
all the June 2000 CT scan and flexion and extension films that several doctors
reported as depicting the dislodged hardware and resulting nerve root impingement
and as supporting Gorski's claims regarding the extent of her pain. Without such a
discussion, Dr. Soriano's report is simply an unreasoned and unexplained rejection
of the objective evidence in the record, Gorski's claims regarding her level of
pain and functionality, and the opinions of Drs. Huffmon and Faircloth that she
was totally disabled. MetLife was not justified in rejecting the opinions of Drs.
Faircloth and Hoffman as well as Gorski's statements on the basis of such a flawed
report. See  Stup, 390 F.3d at 308 ("[W]hile an administrator does not necessarily
abuse its discretion by resolving an evidentiary conflict to its advantage, the
conflicting evidence on which the administrator relies in denying coverage must be
'substantial'-especially when ... the administrator has an economic incentive to
deny benefits ."). Thus, it cannot be said that MetLife's decision was "the result
of a deliberate, principled reasoning process." Id. at 307;see  Black & Decker
Disability Plan v. Nord, 538 U.S. 822, 834 (2003) ("Plan administrators ... may
not arbitrarily refuse to credit a claimant's reliable evidence, including the
opinions of a treating physician.");  Buffonge v. Prudential Ins. Co. of Am., 426
F.3d 20, 30-31 (1st Cir.2005) (holding that denial was not "reasoned" when it
relied in part on fundamentally flawed medical reports).

*8 MetLife contends that it acted reasonably in upholding its termination of
Gorski's benefits because the record contains conflicting evidence concerning
whether she could perform her job as an administrative assistant. In this regard,
MetLife argues that the functional limitations reported by Drs. Huffmon and
Faircloth would not prevent Gorski from undertaking many of the duties of a
secretary, and MetLife notes that Dr. Levine had also concluded that Gorski should
be capable of doing some sedentary activities. MetLife further argues that Dr.
Huffmon did not provide any explanation for his asserted sitting limitations for
Gorski or even indicate that he had examined her in the several months preceding
his assertion. Finally, MetLife points to the video surveillance as a basis for
discrediting Gorski's claimed pain and limitations, on which the other doctors'
opinions of her limitations