Insurance – Long-Term Disability Benefits – Limited Medical Conditions

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The district court did not err when it determined that Plaintiff did not meet his burden of proving long-term disability under the terms of the plan.

We affirmed the district court’s opinion.

Plaintiff Tracy Penland sought restoration of long-term disability benefits under his former employer’s long-term disability plan, which is administered by Metropolitan Life Insurance Company. Having exhausted MetLife’s appeals process, he filed suit in district court under the Employee Retirement Income Security Act of 1974 (ERISA). The district court determined that Penland had not met his burden of proving long-term disability under the terms of the plan.

The record provided ample evidence that Penland experiences significant pain. And, based on this record, nobody can dispute that Penland’s conditions render him unable to fully enjoy daily life. But this appeal solely concerned the question of whether the terms of the plan provide for Penland’s continued receipt of long-term disability benefits or whether those terms preclude coverage due to the lifetime-maximum-coverage provision.

Penland first argued the district court erred by interpreting the plan’s limitation provision to require him to prove disability without reference to limited medical conditions. The plan states that benefits are limited to 24 months if a claimant is disabled “due to” conditions including neuromuscular, musculoskeletal, or soft tissue disorder. Penland contended that when there is “a plan term stating that disabilities due to certain conditions are limited, an insurer is required to perform a review that encompasses the totality of a claimant’s medical conditions, including those that would be limited by the policy if they were the sole cause of the disability.” But, as the district court pointed out, the ordinary meaning of “due to” is “because of,” which, in turn, “connotes a but-for causation standard.” And an event can have multiple but-for causes. So, the argument that non-limited conditions must be the “sole cause” of the disability for the provision to apply fails based on the ordinary meaning of the words in the provision. Consequently, the district court did not err when it did not consider Penland’s limited conditions.

Next, Penland argued his case falls under an exception to the limitation provision because he presented objective evidence of radiculopathy. He did so by pointing to the medical records he provided from Dr. Patel. Dr. Patel incorporates into his file the diagnoses of two other doctors who had examined a 2019 MRI of Penland’s back, both of whom reported that he had symptoms related to radiculopathy. So, Dr. Patel included “radiculopathy” under his assessment for each of his nine appointments with Penland. But nowhere in the record does Dr. Patel explain how he reached the diagnosis of radiculopathy; he only states the conclusion. Penland argued that “Dr. Patel need not offer any reason or explanation because the MRI itself supports the diagnosis of radiculopathy based on the information contained therein as well as the interpreting physician’s findings.” But the record does not contain the MRI, nor does it contain the findings of the interpreting physicians. For this reason, the district court rightly assessed that “although his notes quote the findings of two physicians who interpreted Penland’s 2019 MRI, Dr. Patel does not offer any reasoning or explanation for why the MRI supported his diagnoses.”

Penland contended the district court committed clear error by finding that he had not met his burden of showing “Disability” under the plan. Penland claimed the district court erred when it determined that his non-limited conditions leave him able to earn more than 60% of his pre-disability earnings. To substantiate this point, he argued that the district court should have given more weight to the opinion of Nurse Cox rather than to MetLife’s independent consulting physicians. The district court explained its reasoning for discounting Nurse Cox’s opinion, writing that the “two-page statement of disability, however, is largely conclusory and is entitled to little weight” because she “simply listed Penland’s twelve conditions, noted his subjective symptoms, and then stated her conclusion” that he was disabled.

Penland noted that the termination of benefits occurred during the height of the COVID-19 pandemic when many of his appointments were conducted through telehealth and fewer medical records were generated. But that would not have precluded Penland from gathering already existing evidence, such as the 2019 MRI, or asking Nurse Cox for a more thorough written report. Finally, Penland attempted to discredit independent medical consultant Dr. Pietruszka’s report because it discussed each condition individually as opposed to the combined effect of all of Penland’s conditions. But the district court found that, because Pietruszka had stated that Penland did not suffer “from a medical condition or combination of conditions of such severity to warrant” limitations, Pietruszka “evaluated Penland’s conditions as a whole, rather than in isolation.” It was not clear error for the district court to come to this conclusion.

Affirmed.

Penland v. Metropolitan Life Insurance Company (Lawyers’ Weekly No. 003-019-25, 12 pp.) (James A. Wynn, J.) Appealed from the U.S. District Court for the District of South Carolina, at Anderson (Henry M. Herlong, Jr., J.) On Brief: M. Leila Louzri, Foster Law Firm, LLC, Greenville, South Carolina, for Appellant; J. Derrick Quattlebaum, Jonathan D. Klett, Haynsworth Sinkler Boyd, P.A., Greenville, South Carolina, for Appellee. U.S. Court of Appeals for the Fourth Circuit Unpublished