Majeski v MetLife Webinar Presentation

FIVE LESSONS AND SUGGESTIONS FOR PRACTICE FOR FUNCTIONAL CAPACITY EVALUATORS WEBINAR WITH ROY MATHESON OPEN DISCUSSION AT END OF PRESENTATION March 4, 2010 Copyright 2010 Telephone 603-358-6525 Majeski v. Metropolitan Life

MetLife Short Term Disability Plan Governed by the Employee Retirement Income Security Act (ERISA) The Case

We will review the case from the point-of-view of the “Thinking Evaluator”
The Case

The reason for referral and referral questions are paramount
Always be faithful to the Practice Hierarchy
Safety
Reliability
Validity
Practicality
Utility
The Thinking Evaluator

This appeal concerns MetLife’s decision to reject Majeski’s claim for short-term disability benefits. Overview of the Case The Background 6 No. 09-1930

As the plan administrator MetLife determined that Majeski had failed to submit enough evidence to support her claim. Overview of the Case The Background 6 No. 09-1930

Majeski filed suit, but the district court granted summary judgment against her. Overview of the Case The Background 6 No. 09-1930

Although MetLife’s determination is entitled to deferential review… Overview of the Case The Background 6 No. 09-1930

…the court concludes that there are such significant gaps in the evidence supporting MetLife’s decision that further proceeding are necessary. Overview of the Case The Background 6 No. 09-1930

Lesson One
Take the time to read court cases
http://www.ddbchicago.com/archives/Leger_7th_Cir_Ct_Dec.pdf
http://www.law.cornell.edu/supct/html/02-469.ZS.html
Continual study strengthens your skills
http://www.courts.gov.bc.ca/jdb-txt/SC/10/02/2010BCSC0267.htm

Lesson Two
Understand the audience for your FCE
Short-term disability policies often use the occupation, not the job, as the basis of the claim
The occupation is defined by reference to Department of Labor sources rather than a job analysis or job description
2 and 13 No. 09-1930

Lesson Two
The policy sets the definitions
MetLife’s Short Term Disability Plan defines “disabled” as, “when, as a result of illness or accidental injury [she] is receiving appropriate care and treatment from a doctor on a continuing basis” and “unable to earn more than 80% of [her] pre-disability earnings at [her] own occupation for any employer in [the] local economy”.
2 No. 09-1930

Lesson Two
Majeski also argues that MetLife unreasonably attempted to “reclassify” her work status from a sedentary-level nurse consultant to a medium-level registered nurse.
13 No. 09-1930

Lesson Three
Have the proper references at hand
Dictionary of Occupational Titles
Selected Characteristics of Occupations
Transitional Classification of Jobs
Multidimensional Task Ability Profile (MTAP)
A job calibrated self-report measure with built-in full effort indicators
2 and 13 No. 09-1930

Lesson Three
Have the proper references at hand
Be careful of FCE brokers who do not provide reasons for referral, case records or medical records.

Lesson Four
Read the summary of the Court’s opinion
MetLife determined that Majeski had failed to submit enough evidence to support her (short term disability) claim.
Majeski filed suit but the district court granted summary judgment against her.
1 and 2 No. 09-1930

Lesson Four
Read the summary of the Court’s opinion
“ Although MetLife’s determination is entitled to deferential review, we conclude that there are such significant gaps in the evidence supporting its decision that further proceedings are necessary.”
1 and 2 No. 09-1930

Lesson Five
Find points interesting to an evaluator
Arbitrary-and-capricious decisions (6 No. 09-1930)
How to consider a plan administrator’s conflict of interest (procedural reasonableness) (7 No. 09-1930)
Consideration of evidence that is not part of the administrative record (8 No. 09-1930)
Federal Rules of Evidence – written report
Deferential review versus de novo (8 No. 09-1930)
Whether Majeski’s functional limitations were objectively documented (12 No. 09-1930)

Lesson Five
Arbitrary-and-capricious decisions
“ We cannot square MetLife’s treatment of Hardin’s evaluation and Dr. Weiss’s questionnaire with Leger and Love ’s insistence that procedural reasonableness is the cornerstone of the arbitrary-and-capricious inquiry.”
Love v. National City Corp. Welfare Benefits Plan, Seventh Circuit
“ We found it arbitrary and capricious for a plan administrator “simply [to] ignore” a treating physician’s medical conclusion and to “dismiss [other] conclusions without explanation.”
11 No. 09-1930

Lesson Five
Procedural reasonableness
“ Leger explains that arbitrary-and-capricious review turns on whether the plan administrator communicated “specific reasons” for its determination to the claimant, whether the plan administrator afforded the claimant “an opportunity for full and fair review,” and “whether there is an absence of reasoning to support the plan administrator’s determination.” 557 F.3d at 832-33
7, 10, 11 No. 09-1930

Lesson Five
But a plan administrator’s procedures are not reasonable if its determination ignores, without explanation, substantial evidence that the claimant has submitted that addresses what the plan itself has defined as the ultimate issue — here, whether Majeski’s functional limitations were objectively documented.
12 No. 08-1362

Lesson Five
In Leger , we held that it was arbitrary and capricious for a plan administrator to “ignore” and “dismiss out of hand” evidence in a functional-capacity evaluation that a claimant was not capable of sitting, concluding this was an “absence of reasoning in the record.”
10 No. 08-1362

Lesson Five
Williams v. Aetna Life Ins. Co., Seventh Circuit
A plan may deny benefits because a claimant has failed properly to document pain-induced functional limitations
11 No. 1:06-cv-01136

Lesson Five
No obligation to accord special deference to the opinions of treating physicians
The Black and Decker Disability Plan v. Kenneth L. Nord, Ninth Circuit
We hold that plan administrators are not obliged to accord special deference to the opinions of treating physicians.
1 No. 02-469

Valuable Gift
This case is a useful training tool for functional capacity evaluators
Comments should not be taken as criticism of those that were involved in the case

Comments/Questions? www.roymatheson.com [email_address] 1-800-443-7690 +1-603-358-6525 Find us on Facebook

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Majeski v MetLife Webinar Presentation

by Roy Matheson & Associates, Inc on Mar 11, 2010

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Majeski v MetLife Webinar Presentation — Presentation Transcript