Sutton v. MetLife – LTD Policy Requires Objective Evidence, Not Conclusive Proof

The plaintiff, Sutton, filed a lawsuit against MetLife, the defendant, for the wrongful denial of long-term disability benefits under his employer’s plan governed by ERISA (Employee Retirement Income Security Act).

Background

Under the disability plan’s policy documents, if an employee’s disability is attributable to a neuromuscular or musculoskeletal condition, benefits are normally paid for only twenty-four months, even if the disability persists beyond twenty-four months, and even if the disability prevents the employee from earning any income. There is one exception to this twenty-four-month limit. Employees may continue to receive benefits beyond twenty-four months if “the Disability has objective evidence of” at least one of six listed conditions.

Only two of the six listed conditions are relevant to this case. The core dispute was whether there was “objective evidence” of myelopathy or spinal cord damage, as required by the policy, to continue receiving benefits beyond a 24-month period.

As the twenty-four-month mark approached, MetLife reviewed Sutton’s medical records and informed him that it would not pay benefits beyond twenty-four months because it had found no “objective evidence” of myelopathy or spinal cord damage.

Sutton appealed that decision in an internal administrative process. In response, MetLife hired Dr. John Zheng, board-certified in physical medicine, rehabilitation, and pain medicine, to review Sutton’s medical records. Zheng found no “objective evidence of myelopathy.”

MetLife forwarded Zheng’s opinions to Sutton’s counsel, who responded with additional medical records, including the reports of his 2021 x-ray and MRI, which had not been completed at the time of MetLife’s original denial, and a statement from Dr. Blake, Sutton’s pain management specialist. However, the new evidence did not offer a diagnosis of spinal cord damage or myelopathy, and Dr. Blake did not ascribe Sutton’s pain to spinal cord damage or myelopathy. MetLife then asked Zheng if the new information changed his opinion, but it did not.

MetLife sent Zheng’s updated assessment to Sutton’s counsel, who contended MetLife had required more evidence from Sutton than the plan demanded. He pointed out that Sutton’s symptoms—such as pain, numbness, and absent reflexes in his legs—could be attributable to myelopathy. Nonetheless, Zheng believed Sutton had not identified any objective evidence of myelopathy. MetLife upheld its decision to deny benefits beyond twenty-four months, citing a lack of “objective evidence” of myelopathy. Sutton then filed this case in the United States District Court for the Eastern District of California.

Legal Standard

The case was subject to “de novo” review, meaning the court independently examined and decided whether the plan administrator erred. Under ERISA guidelines and federal common law, ambiguities in the policy are resolved in favor of the plan participant, and exclusions should be construed to promote coverage.

MetLife’s Arguments

MetLife’s arguments against Sutton were based on their interpretation of the medical evidence and the policy terms:

1. Medical Evidence Assessment: On behalf of MetLife, Dr. Zheng reviewed Sutton’s medical files and concluded that the records did not indicate myelopathy. His reasons included Sutton’s ability to walk and move his limbs normally, a 2021 MRI report stating there was no significant central canal stenosis and most findings related to a region in the spine without a spinal cord, and that absent reflexes alone do not suggest myelopathy.
2. Negative Inferences from the Record: MetLife highlighted that there were no references to myelopathy in the records of Sutton’s spinal surgeon, the x-ray and MRI reports, Dr. Blake’s letter, or the award letter granting Sutton Social Security Disability Insurance benefits.
3. Interpretation of Policy Provisions: MetLife argued that because there was no explicit, conclusive, objective evidence of myelopathy or spinal cord damage in Sutton’s medical records, benefits were correctly denied. They seemed to interpret the policy as requiring such conclusive evidence to grant the continuation of benefits.
4. Dr. Blake’s Records: MetLife pointed to Dr. Blake’s records, which explicitly stated Sutton had “spondylosis without myelopathy,” suggesting that this contradicted Sutton’s claim of having myelopathy.

MetLife’s position was that the objective evidence required by the policy to establish myelopathy or spinal cord damage was not met in Sutton’s case, and thus, they were justified in denying the continuation of his long-term disability benefits.

Sutton’s Arguments

Sutton’s arguments against MetLife were based on the contention that there was indeed “objective evidence” of myelopathy or spinal cord damage, as required by the terms of his long-term disability plan. The key points of Sutton’s arguments included:

1. Presence of Objective Evidence: Sutton cited objective medical evidence, such as clinical observations of reduced or absent reflexes in his legs, which are considered signs that could be attributed to myelopathy. He also pointed to MRI and X-ray reports indicating spinal stenosis and spondylosis, conditions that can cause myelopathy.
2. Interpretation of Policy Language: Sutton argued that the policy language was ambiguous and should be resolved in his favor. He emphasized that the plan required only “some” objective evidence that tends to prove myelopathy or spinal cord damage rather than conclusive proof.
3. Challenge to MetLife’s Review Process: He questioned the reliability of Dr. Zheng’s opinions because Dr. Zheng only reviewed files and did not examine Sutton personally or consult with his doctors, nor did he review medical images firsthand.
4. Critique of MetLife’s Inferences: Sutton contended that MetLife’s negative inferences from the administrative record were unfounded and that the absence of explicit mentions of myelopathy in certain documents did not equate to the absence of objective evidence of the condition.

Sutton’s case was built around challenging the insurance company’s interpretation and application of the policy terms and the adequacy of their review process, aiming to show that the denial of benefits was erroneous under the Employee Retirement Income Security Act (ERISA) standards.

The Court’s Decision

The court decided in favor of Sutton, concluding that MetLife had erroneously denied him benefits. The court found that Sutton provided sufficient objective evidence within the administrative record to establish the presence of myelopathy or spinal cord damage as required by the terms of his employer’s long-term disability plan. This evidence included clinical observations of reduced or absent reflexes and MRI and X-ray reports that suggested spinal stenosis and spondylosis, which can cause myelopathy.

Per ERISA guidelines, the court interpreted the policy language in favor of the plan participant, requiring only some objective evidence tending to establish myelopathy or spinal cord damage, not conclusive proof. It dismissed MetLife’s arguments that minimized this evidence, including doubts cast by their paid consultant, Dr. Zheng, who did not examine Sutton personally. The court also held that it could not affirm MetLife’s denial based on the reasoning the company did not rely on at the time of the denial.

The court concluded that Sutton met his burden under ERISA to show that benefits were wrongly denied and ruled against MetLife’s decision to deny the long-term disability benefits beyond the initial twenty-four months.

Here is a PDF copy of the decision: Sutton v. MetLife

Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.