904 F.3d 532
7th Cir.2018Background
- Susan Hennen, an NCR employee, received long-term disability (LTD) benefits from MetLife after back surgery; the plan caps coverage for neuromusculoskeletal disorders at two years unless an exception (e.g., radiculopathy) is shown with objective evidence.
- Hennen had a history of lumbar pathology and surgeries; post‑surgery she reported radiating leg pain and underwent MRIs, epidural injections, implantation of a spinal cord stimulator, and other treatments.
- Multiple treating physicians (including Drs. Buvanendran, Kipta, Malik, Margolis, and Calisoff) recorded signs consistent with nerve-root pathology and several diagnosed radiculopathy or radiculitis; an EMG performed in June 2015 was read by Dr. Kipta and Dr. Malik as supporting radiculopathy.
- MetLife’s medical director (Dr. Adewumni) agreed the EMG supported radiculopathy, but MetLife then obtained a file-review from Dr. McPhee (asked only about functional limitations), who concluded the EMG and MRI did not show active radiculopathy and recommended further testing/IME.
- MetLife credited Dr. McPhee, declined to pursue the additional testing he recommended, terminated Hennen’s benefits as falling within the two‑year limit, and upheld that denial on administrative appeal; Hennen sued under ERISA § 1132(a)(1)(B).
- The district court granted summary judgment to MetLife; the Seventh Circuit reversed and remanded, finding MetLife’s denial arbitrary and capricious because it discounted multiple examining physicians and ignored Dr. McPhee’s recommendation for further testing.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether MetLife’s termination of LTD benefits was arbitrary and capricious under the plan’s grant of discretion | Hennen: MetLife arbitrarily discredited multiple treating/examining physicians and the EMG supporting radiculopathy, and improperly relied on one file-reviewer without following his recommendation for more testing | MetLife: Reasonably credited Dr. McPhee’s file review; no obligation to order additional testing; decision supported by a rational medical opinion | Reversed and remanded: MetLife acted arbitrarily by favoring Dr. McPhee’s contrary view while ignoring his advice to obtain further testing/IME and by discounting several examining doctors’ opinions |
| Whether objective evidence of radiculopathy existed to trigger the radiculopathy exception to the two-year limit | Hennen: Clinical findings and the June 2015 EMG provide objective evidence of radiculopathy as defined by the plan | MetLife: MRI/EMG did not show nerve compression or active radiculopathy; objective proof lacking | Court: The record contains substantial objective findings and competing medical opinions; MetLife’s selective reliance was unreasonable and requires reassessment on remand |
| Whether MetLife violated its fiduciary duties in processing the claim | Hennen: MetLife breached fiduciary duty by failing to pursue further testing recommended by its reviewer and by prioritizing plan interests | MetLife: Acted within discretionary authority and based decision on a reviewing physician’s report | Court: Fiduciary duty implicated; MetLife should have followed up on the reviewer’s recommendation before denying benefits; remand required |
| Appropriate remedy where procedure was deficient | Hennen: Remand for proper administrative reconsideration and development of the record; not entitlement to automatic benefits | MetLife: Denial stands; no additional procedures required | Court: Remand to MetLife to reassess claim consistent with opinion; denial not automatically converted to award |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1978) (standard for judicial review of ERISA benefit denials)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (no presumption favoring treating/examining physicians over file reviewers)
- Glenn v. Metropolitan Life Ins. Co., 554 U.S. 105 (2008) (conflict of interest as a factor in abuse-of-discretion review)
- Becker v. Chrysler LLC Health Care Benefits Plan, 691 F.3d 879 (7th Cir. 2012) (administrator may choose between medical opinions if rationale supported by record)
- Holmstrom v. Metropolitan Life Ins. Co., 615 F.3d 758 (7th Cir. 2010) (administrator’s failure to explain or pursue necessary steps can render denial arbitrary)
- Tompkins v. Central Laborers’ Pension Fund, 712 F.3d 995 (7th Cir. 2013) (standards for reviewing discretionary benefit determinations)
- Hackett v. Xerox Corp. Long-Term Disability Income Plan, 315 F.3d 771 (7th Cir. 2003) (remedying deficient administrative procedures on remand)
- Gaither v. Aetna Life Ins. Co., 394 F.3d 792 (10th Cir. 2004) (fiduciary duty to ensure entitled beneficiaries receive plan benefits)