Gabe Baker and Steve Jensen give a good analysis of this case.

In Judge v. Metropolitan Life Insurance Company [PDF], 710 F.3d 651 (6th Cir. 2013), the Sixth Circuit rejected plaintiff’s proposed bright-line rule requiring plan administrators to obtain vocational evidence and an IME before making their determination.  However, those steps may be required depending on the particular facts of a claim.

FACTS: Claimant Thomas Judge, a baggage handler and ramp agent for Delta Airlines, applied for benefits following heart surgery.  He submitted a series of post-surgery assessments prepared by his treating physicians.  An April 2010 assessment restricted lifting to no more than 15 pounds.  A July 2010 report indicated he could lift up to 50 pounds and could participate in mild to moderate aerobic activity. October and December 2010 reports indicated that he could work eight hours per day, but limited him to two hours sitting and no standing or walking.

A MetLife nurse consultant reviewed the reports, and determined that Judge did not meet the definition of disability under the plan.  On appeal another nurse reviewed the records and concurred with the first nurse’s analysis.  Applying the arbitrary and capricious standard, the district court granted judgment in favor of MetLife.  Judge then appealed to the Sixth Circuit.

KEY ISSUES:

• Was MetLife required to obtain vocational evidence before making its determination? NO.
• Was MetLife required to send Judge for an IME before making its determination? NO.
• Was MetLife required to use a doctor, rather than a nurse, to review Judge’s medical files?  NO.

HOLDING–Affirmed:

1.     “[A] plan administrator is not required to obtain vocational evidence where the medical evidence contained in the record provides substantial support for a finding that the claimant is not totally and permanently disabled.  Applying this principle to the present case, we hold that MetLife was not required to obtain vocational evidence…” 710 F.3d at 662-3.

2.    In some cases, “[a] plan administrator’s decision to conduct a file-only review (rather than getting an IME) might raise questions about the benefits determination, particularly when the right to conduct a physical examination is specifically reserved in the plan.”  710 F.3d at 663.  In particular, a file-only review may be questionable when either “the file reviewer concludes that the claimant is not credible without having actually examined him or her” or “the plan administrator, without any reasoning, credits the file reviewer’s opinion over that of a treating physician.”  Id.  In this case, the file reviewers “made no credibility determinations about Judge and did not second-guess Judge’s treating physicians.”  Id.  For those reasons, the court held that “MetLife did not act arbitrarily or capriciously in conducting a file review.”  Id.

3.     In regard to the use of nurse for the file review, the court held: “Judge’s argument that MetLife acted arbitrarily and capriciously in referring his file to a nurse for review, rather than to a physician, is meritless.”  710 F.3d at 663.