Gordon v. Metropolitan Life Insurance Company

Background

Robert Gordon sought long-term disability benefits under the Borland Software Corporation Long Term Disability Plan, an employee-benefit plan governed by the Employee Retirement Income Security Act of 1974. Metropolitan Life Insurance Company funded the benefits and administered claims under the plan. Gordon claimed that depression, anxiety, post-traumatic stress symptoms, and spinal, knee, and shoulder conditions left him totally disabled.

The plan required a claimant to receive appropriate, continuing medical care and to be unable to earn more than 80% of predisability earnings in the claimant’s “Own Occupation” for any employer in the claimant’s local economy. The plan defined “Own Occupation” more broadly than the specific position held for the employer. It also required a 90-day elimination period and imposed a 24-month limit for disabilities caused by mental or nervous disorders. Gordon’s coverage ended when his employment ended on May 1, 2002.

Gordon submitted his benefits claim in 2009, asserting disability beginning April 19, 2002. MetLife denied the claim in 2012, and Gordon appealed, but MetLife did not issue a formal appeal decision. After earlier proceedings, the Ninth Circuit held that the denial should be reviewed independently rather than deferentially and that competing medical opinions created a genuine factual dispute. The parties then filed competing motions for judgment under Federal Rule of Civil Procedure 52.

Court’s analysis

The court conducted a de novo review, meaning it independently evaluated whether the benefit claim should have been approved. The court treated Gordon as having the burden of proving that he met the plan’s definition of disability while he was covered.

The court found that records from Drs. Jane Koopman and Dean G. Zweng showed that Gordon was receiving mental-health care in April 2002, which might satisfy the plan’s continuing-care requirement. But neither doctor concluded that Gordon was unable to work in his occupation for any employer in his local economy. Dr. Koopman initially excused him from work for one week and later approved a return to work with a change of manager or department. Dr. Zweng released him to return to regular work. The court found that these opinions were inconsistent with Gordon’s claim that he could not work during the elimination period and the following 60 months.

The court reached a similar conclusion regarding Dr. William C. Mears’s May 1, 2002 notes. Dr. Mears related Gordon’s anxiety and depression to stress under a particular supervisor and stated that Gordon could return to work if he did not remain in the same department. The court concluded that this did not establish an inability to work in the same occupation for another employer.

The court also considered later records and opinions. It gave minimal weight to Dr. Abarbanel’s 2014 letter because it was prepared more than ten years after the claimed disability began and because he first evaluated Gordon after coverage ended. The court found that Dr. Abarbanel’s later disability certifications, Dr. Michael G. Meade’s 2003 assessment, and later physical evaluations did not establish that Gordon satisfied the plan’s requirements before May 1, 2002. The court also found insufficient evidence of continuing treatment for chronic pain before that date.

The court credited the opinions of MetLife’s reviewing physicians, Drs. Lee Becker, Peter Sugerman, and Jane St. Clair. Those physicians concluded that the records did not establish psychiatric or physical limitations severe enough to prevent Gordon from working in his occupation for another employer during the relevant period. The court rejected Gordon’s arguments that the reviewers’ compensation or criticisms in other cases made their opinions unreliable. It also found the contemporaneous April and May 2002 records more reliable than later opinions about Gordon’s condition.

Disposition

The court held that Gordon did not prove that he became disabled within the meaning of the plan before his coverage ended. The court denied Plaintiff’s motion for judgment under Rule 52 and granted Defendant’s cross-motion for judgment under Rule 52.