FIVE  LESSONS AND SUGGESTIONS FOR PRACTICE FOR FUNCTIONAL CAPACITY EVALUATORS WEBINAR WITH ROY MATHESON OPEN DISCUSSION AT...
MetLife Short Term Disability Plan Governed by the Employee Retirement Income Security Act (ERISA)  The Case
<ul><li>We will review the case from the point-of-view of the “Thinking Evaluator” </li></ul>The Case
<ul><li>The reason for referral and referral questions are paramount </li></ul><ul><li>Always be faithful to the Practice ...
This appeal concerns MetLife’s decision to reject Majeski’s claim for short-term disability benefits. Overview of the Case...
As the plan administrator MetLife determined that Majeski had failed to submit enough evidence to support her claim. Overv...
Majeski filed suit, but the district court granted summary judgment against her. Overview of the Case The Background 6 No....
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 proce...
Lesson One <ul><li>Take the time to read court cases </li></ul><ul><ul><li>http://www.ddbchicago.com/archives/Leger_7th_Ci...
Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>Short-term disability policies often use the...
Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>The policy sets the definitions </li></ul></...
Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>Majeski also argues that MetLife unreasonabl...
Lesson Three <ul><li>Have the proper references at hand </li></ul><ul><ul><ul><li>Dictionary of Occupational Titles </li><...
Lesson Three <ul><li>Have the proper references at hand </li></ul><ul><ul><li>Be careful of FCE brokers who do not provide...
Lesson Four <ul><li>Read the summary of the Court’s opinion </li></ul><ul><ul><li>MetLife determined that Majeski had fail...
Lesson Four <ul><li>Read the summary of the Court’s opinion </li></ul><ul><ul><li>“ Although MetLife’s determination is en...
Lesson Five <ul><li>Find points interesting to an evaluator </li></ul><ul><ul><li>Arbitrary-and-capricious decisions (6 No...
Lesson Five <ul><li>Arbitrary-and-capricious decisions </li></ul><ul><ul><li>“ We cannot square MetLife’s treatment of Har...
Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>“ Leger  explains that arbitrary-and-capricious review...
Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>But a plan administrator’s procedures are not reasonab...
Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>In  Leger , we held that it was arbitrary and capricio...
Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>Williams v. Aetna Life Ins. Co., Seventh Circuit </li>...
Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>No obligation to accord special deference to the opini...
Valuable Gift <ul><li>This case is a useful training tool for functional capacity evaluators </li></ul><ul><li>Comments sh...
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

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On March 4th Roy held a free webinar to share his analysis of the recent Majeski vs. Metropolitan Life case and to have an open discussion with colleagues. Reviewing the case from the point-of-view of a "Thinking Evaluator", Roy discussed five lessons and suggestions for practice for functional capacity evaluators.

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Majeski v MetLife Webinar Presentation

  1. 1. 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
  2. 2. MetLife Short Term Disability Plan Governed by the Employee Retirement Income Security Act (ERISA) The Case
  3. 3. <ul><li>We will review the case from the point-of-view of the “Thinking Evaluator” </li></ul>The Case
  4. 4. <ul><li>The reason for referral and referral questions are paramount </li></ul><ul><li>Always be faithful to the Practice Hierarchy </li></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Reliability </li></ul></ul><ul><ul><li>Validity </li></ul></ul><ul><ul><li>Practicality </li></ul></ul><ul><ul><li>Utility </li></ul></ul>The Thinking Evaluator
  5. 5. 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
  6. 6. 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
  7. 7. Majeski filed suit, but the district court granted summary judgment against her. Overview of the Case The Background 6 No. 09-1930
  8. 8. Although MetLife’s determination is entitled to deferential review… Overview of the Case The Background 6 No. 09-1930
  9. 9. …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
  10. 10. Lesson One <ul><li>Take the time to read court cases </li></ul><ul><ul><li>http://www.ddbchicago.com/archives/Leger_7th_Cir_Ct_Dec.pdf </li></ul></ul><ul><ul><li>http://www.law.cornell.edu/supct/html/02-469.ZS.html </li></ul></ul><ul><li>Continual study strengthens your skills </li></ul><ul><ul><li>http://www.courts.gov.bc.ca/jdb-txt/SC/10/02/2010BCSC0267.htm </li></ul></ul>
  11. 11. Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>Short-term disability policies often use the occupation, not the job, as the basis of the claim </li></ul></ul><ul><ul><li>The occupation is defined by reference to Department of Labor sources rather than a job analysis or job description </li></ul></ul>2 and 13 No. 09-1930
  12. 12. Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>The policy sets the definitions </li></ul></ul><ul><ul><ul><li>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”. </li></ul></ul></ul>2 No. 09-1930
  13. 13. Lesson Two <ul><li>Understand the audience for your FCE </li></ul><ul><ul><li>Majeski also argues that MetLife unreasonably attempted to “reclassify” her work status from a sedentary-level nurse consultant to a medium-level registered nurse. </li></ul></ul>13 No. 09-1930
  14. 14. Lesson Three <ul><li>Have the proper references at hand </li></ul><ul><ul><ul><li>Dictionary of Occupational Titles </li></ul></ul></ul><ul><ul><ul><li>Selected Characteristics of Occupations </li></ul></ul></ul><ul><ul><ul><li>Transitional Classification of Jobs </li></ul></ul></ul><ul><ul><ul><li>Multidimensional Task Ability Profile (MTAP) </li></ul></ul></ul><ul><ul><ul><ul><li>A job calibrated self-report measure with built-in full effort indicators </li></ul></ul></ul></ul>2 and 13 No. 09-1930
  15. 15. Lesson Three <ul><li>Have the proper references at hand </li></ul><ul><ul><li>Be careful of FCE brokers who do not provide reasons for referral, case records or medical records. </li></ul></ul>
  16. 16. Lesson Four <ul><li>Read the summary of the Court’s opinion </li></ul><ul><ul><li>MetLife determined that Majeski had failed to submit enough evidence to support her (short term disability) claim. </li></ul></ul><ul><ul><li>Majeski filed suit but the district court granted summary judgment against her. </li></ul></ul>1 and 2 No. 09-1930
  17. 17. Lesson Four <ul><li>Read the summary of the Court’s opinion </li></ul><ul><ul><li>“ 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.” </li></ul></ul>1 and 2 No. 09-1930
  18. 18. Lesson Five <ul><li>Find points interesting to an evaluator </li></ul><ul><ul><li>Arbitrary-and-capricious decisions (6 No. 09-1930) </li></ul></ul><ul><ul><li>How to consider a plan administrator’s conflict of interest (procedural reasonableness) (7 No. 09-1930) </li></ul></ul><ul><ul><li>Consideration of evidence that is not part of the administrative record (8 No. 09-1930) </li></ul></ul><ul><ul><ul><li>Federal Rules of Evidence – written report </li></ul></ul></ul><ul><ul><li>Deferential review versus de novo (8 No. 09-1930) </li></ul></ul><ul><ul><li>Whether Majeski’s functional limitations were objectively documented (12 No. 09-1930) </li></ul></ul>
  19. 19. Lesson Five <ul><li>Arbitrary-and-capricious decisions </li></ul><ul><ul><li>“ 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.” </li></ul></ul><ul><ul><li>Love v. National City Corp. Welfare Benefits Plan, Seventh Circuit </li></ul></ul><ul><ul><ul><li>“ 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.” </li></ul></ul></ul>11 No. 09-1930
  20. 20. Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>“ 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 </li></ul></ul>7, 10, 11 No. 09-1930
  21. 21. Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>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. </li></ul></ul>12 No. 08-1362
  22. 22. Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>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.” </li></ul></ul>10 No. 08-1362
  23. 23. Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>Williams v. Aetna Life Ins. Co., Seventh Circuit </li></ul></ul><ul><ul><ul><li>A plan may deny benefits because a claimant has failed properly to document pain-induced functional limitations </li></ul></ul></ul>11 No. 1:06-cv-01136
  24. 24. Lesson Five <ul><li>Procedural reasonableness </li></ul><ul><ul><li>No obligation to accord special deference to the opinions of treating physicians </li></ul></ul><ul><ul><ul><li>The Black and Decker Disability Plan v. Kenneth L. Nord, Ninth Circuit </li></ul></ul></ul><ul><ul><ul><ul><li>We hold that plan administrators are not obliged to accord special deference to the opinions of treating physicians. </li></ul></ul></ul></ul>1 No. 02-469
  25. 25. Valuable Gift <ul><li>This case is a useful training tool for functional capacity evaluators </li></ul><ul><li>Comments should not be taken as criticism of those that were involved in the case </li></ul>
  26. 26. Comments/Questions? www.roymatheson.com [email_address] 1-800-443-7690 +1-603-358-6525 Find us on Facebook

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