Will a Fresh Review of Medical Evidence Produce a Fairer Result?
San Diego, CAChristopher Wheeler was a Coxswain/Diesel mechanic, a contractor doing heavy physical work for the U.S. Navy Fifth Fleet. On March 17, 2015, he was badly injured during a storm at sea off Bahrain. Hospitals and rehab landed him a computer job for which he had no aptitude or training. When that didn’t work out, his employer, Exelis, Inc. terminated his employment and Metropolitan Life Insurance (MetLife) denied his long term disability benefit application. He filed a long term denied disability lawsuit on August 2, 2018 in the Southern District of California. California’s de novo standard for the review of disability claims under ERISA may work to Wheeler’s benefit.
Hard and Dangerous Work
Wheeler’s job was to operate and maintain deployed systems (Rigid Hulled Inflatable Boats (RHIBs) and Unmanned Underwater Vehicles (UUVs)) in support of U.S. Navy mine counter-measures. He had to lift, push, pull and carry anywhere from 20 to 100 pounds frequently, while crawling, standing, walking, reaching, sitting, swimming, twisting, and climbing ladders. In addition, he had to be able to make quick decisions that would affect the safety of co-workers. He was a brave man, doing hard physical work.
On March 17, 2015, he and his co-workers were struggling to retrieve a 580 pound UUV out of the water before a storm hit. A problem with the fuel line stalled the retrieval and forced them to lift it during the gale. Ten-foot waves made the operation particularly dangerous. While lifting the UUV on a crane, Wheeler was hit by the craft and thrown onto the deck, where he landed on his lower back. After a five-hour trip back to port, he was taken by ambulance to the nearest hospital. He has never been able to return to his previous job.
Cleared for Duty
About a year after the accident, Wheeler was released to return to full-time employment with significant restrictions and limitations. Excelis assigned him to a computer job. Wheeler was then injured again in a nonindustrial accident, which caused him another brief period of disability. He returned to his computer job in July 2015, where he stayed for another brief time until Excelis terminated his employment for errors in his work product. Wheeler had found the assignment very difficult because he had no computer skills prior to this assignment.
He applied for long term disability benefits under the Excelis Corporate Welfare Plan. His application and appeal were denied because he reportedly did not meet the definition of “disability” under its terms.
A Baffling Decision
Wheeler was, by all accounts, grievously injured in the accident. His medical files describe disc injuries, fractured ribs, chronic, disabling back pain, pain in his neck, shoulder and legs, depression, anxiety, posttraumatic stress disorder and sleep disturbances. From a human perspective, all of this is consistent with the story of a man whose body is broken and who has lost the ability to make a living. How could MetLife have denied this claim?
As described in the Complaint, a MetLife in-house nurse clinician reviewed Wheeler’s physical diagnoses and confirmed findings of mild muscular spasm, disc protrusion at L4 – L5 and mild foraminal narrowing, fractures at the 2nd, 3rd and 4th anterior ribs and somatic dysfunction of the thoracic and sacral regions. She nonetheless concluded that Wheeler was able to return to work at his own occupation.
A MetLife psychiatric clinical specialist who conducted only a medical records review admitted that the report from the treating psychiatrist noted symptoms of depression, PTSD, anxiety and avoidant behavior. However, the specialist similarly opined that there was a lack of documented symptoms to support an inability to perform his own occupation from March 2015, the date of the accident, through the date of his review.
The results raise many questions, especially on the basis of the evidence offered in the Complaint. It is tempting to question the quality, objectivity or the possibility of an inherent conflict of interest when a plan administrator has final say about the plan’s’ financial obligations toward a claimant.
Is it Time to Have a Better Look at Medical Records?
The biggest piece of the puzzle in a claim for long term disability benefits is the medical evidence. The District Courts in many jurisdictions give great deference to a plan administrator’s initial decision about this information, stepping in to reverse an administrative decision only when it can be shown to have been arbitrary and capricious.
The Ninth Circuit, in which the Southern District of California is situated, has been more willing to permit courts to have a fresh, or de novo look at the medical files. Rather than effectively “rubber stamping” an administrative decision that may have been influenced by internal financial considerations or a hasty review of medical files, for example, a court might hear evidence from a claimant’s treating physicians.
That does not necessarily mean that an administrative decision would be overturned, but the chance at a second, fresh review of evidence may be fairer to claimants like Christopher Wheeler, who appear to have suffered from an economic wrong that compounds physical harm. Wheeler’s situation is even more compelling because the risks he took were a matter of course in a job that was important and necessary for national security.
If you or a loved one have suffered losses in this case, please click the link below and your complaint will be sent to an insurance lawyer who may evaluate your LTD Insurance Fraud claim at no cost or obligation.