Sutton v. Metro. Life Ins. Co.

1

Keith Sutton, Plaintiff, v. Metropolitan Life Insurance Company, et al., Defendants.

No. 2:22-cv-00732-KJM-CKD

United States District Court, E.D. California

July 19, 2023

ORDER

Plaintiff Keith Sutton contends he was wrongly denied long-term disability benefits under an employee benefits plan administered by Metropolitan Life Insurance Company (MetLife). He is pursuing a claim against the benefits plan and MetLife under the Employee Retirement Income Security Act (ERISA). As explained below, Sutton has shown that MetLife erroneously denied benefits under the plan.

I. BACKGROUND

The dispute in this case is a narrow one. Under the disability plan's policy documents, if an employee's disability is attributable to a neuromuscular or musculoskeletal condition, benefits are normally paid for only twenty-four months, even if the disability persists beyond twenty-four months, and even if the disability prevents the employee from earning any income at all. See AR 789-790, ECF Nos 028-1 to 028-4. There is one exception to this twenty-four month limit. An employee may continue to receive benefits beyond twenty-four months if “the Disability has objective evidence of' at least one of six listed conditions. See AR 789-90. Only two of the six listed conditions are relevant to this case: “Myelopathies”^[1] and “Spinal Cord Damage.” Id. at 789.

Sutton suffers from back pain that has prevented him from working for several years. See Pl.'s Br. at 3-4, ECF No. 26; Defs.' Br. at 3, ECF No. 27. The parties do not currently dispute he is disabled under the terms of the plan, and they do not dispute his condition is neuromuscular or musculoskeletal. See Pl.'s Br. at 6; Defs.' Br. at 16-17. By the policy terms summarized above, then, long-term benefits beyond twenty-four months are due to Sutton only if his “Disability has objective evidence of' either “Spinal Cord Damage” or “Myelopathies.” See Pl.'s Reply at 3, ECF No. 34. Sutton and MetLife disagree whether that condition is satisfied, and that is the narrow dispute at the center of this case, as Sutton already has received twenty-four months' benefits.

Sutton's medical records are lengthy and sometimes contradictory. As long ago as 2018, Sutton's physician, Dr. John Lombard, recorded a diagnosis of myelopathy. AR 459, 452. Although Dr. Lombard recorded that diagnosis, he did not discuss the reasons for it or any testing that supported it, such as x-rays or MRIs. Id. MetLife employees also repeatedly wrote in the company's internal records that Sutton was out of work “due to intervertebral lumbar disorder with myelopathy, lumbar region,” among other conditions. See, e.g., AR 1440, 1449, 1452. Like Dr. Lombard's records, most of the MetLife records mention no medical imaging or similar test results. One record does mention an MRI in 2018. AR 1431. A note describes the MRI as showing “moderate central spinal stenosis.”^[2] Id. Spinal stenosis can, in turn, damage the spinal cord or cause myelopathy. See Louis, et al., supra; Joao Levy Melancia, et al., “Spinal Stenosis,” 119 Handbook of Clinical Neurology 541-49, 541 (Dec. 2013); see also, e.g., Huberty v. Standard Ins. Co., No. 06-2388, 2008 WL 783407, at *29 (D. Minn. Mar. 25, 2008).

Other portions of Sutton's medical records expressly rule out myelopathy. In 2018, for example, a note from Sutton's pain management doctor, Jacob Blake, records a diagnosis of “spondylosis without myelopathy or radiculopathy, lumbar region.”^[3] AR 287 (emphasis added). Dr. Blake's records include similar notes as recently as 2020. See AR 1013. But like Dr. Lombard's notes, Dr. Blake's notes do not connect his assessment of no myelopathy to any specific imaging or other test results. See id.

Still other portions of Sutton's medical records are silent or ambiguous. For example, Dr. Kirkham Wood, a surgeon who performed a procedure to alleviate pain in Sutton's back in 2019, assessed the likely causes of Sutton's pain in early 2020. See AR 1035. He did not diagnose Sutton with spinal cord damage or myelopathy but instead ascribed Sutton's back pain to arthritis or some source other than his spine. See AR 1036. Elsewhere his records refer to “spondylolysis” (not to be confused with spondylosis), a condition in which vertebrae slip out of their ordinary alignment. See, e.g.,Maldonado v. Comm'r of Soc. Sec., No. 21-594, 2023 WL 243617, at *4 n.2 (S.D.N.Y. Jan. 18, 2023) (discussing this condition); Stratton v. Life Ins. Co. of N. Am., 589 F.Supp.3d 1145, 1154 n.5 (S.D. Cal. 2022) (same).

Sutton's medical records also include reports of several medical imaging studies, including the 2018 MRI cited in MetLife's notes. According to the MRI report, the scan revealed “anterolisthesis,”^[4] “spondylolysis,” “moderate central canal stenosis,” and “neural foraminal narrowing.”^[5] AR 899. Sutton was also x-rayed in 2018, and the record includes a report of that x-ray. Like the 2018 MRI report, the x-ray report describes anterolisthesis and spondylolysis. Id. Unlike the MRI report, however, it does not mention stenosis. Id. Neither the MRI nor the x-ray mentions spinal cord damage or myelopathy. Sutton also underwent an MRI and x-ray in 2021. According to the report of the later MRI, imaging revealed “[n]o significant central canal stenosis or neural foraminal narrowing.” AR 901. The x-ray report again described anterolisthesis and spondylosis. AR 900. Like the 2018 reports, neither of the 2021 reports refers to myelopathy or spinal cord damage.

Finally, Sutton has reported pain in his back and weakness and numbness in his legs. See, e.g., AR 833-34. In some clinical tests and exams, he has also exhibited diminished or even absent reflexes in his legs or feet. See, e.g., AR 27, 34, 290, 1067.

MetLife reviewed Sutton's medical records and informed him in early 2021 that it would not offer benefits beyond twenty-four months because it had found no “objective evidence” of myelopathy or spinal cord damage. AR 1360-62. Sutton appealed that decision in an internal administrative process. AR 987-1004. In response, MetLife hired Dr. John Zheng, who is board certified in physical medicine, rehabilitation and pain medicine, to review Sutton's medical records. AR 958-65. Zheng found no “objective evidence of myelopathy.” AR 962. He relied on clinical records showing Sutton could walk and move his arms and legs normally despite pain and tenderness in his back. AR 963.

MetLife forwarded Zheng's opinions to Sutton's counsel, who responded with additional medical records, including the reports of his 2021 x-ray and MRI, which had not been completed at the time of MetLife's original denial. See AR 892-905. Sutton's attorneys also forwarded a letter from Dr. Blake, Sutton's pain management specialist. See AR 905. Blake wrote that in his opinion, Sutton was “totally disabled” as a result of his symptoms, which were caused by “[l]ow back pain,” among other diagnoses. Id. Blake cited the x-ray and MRI reports described above, and he quoted those reports, including their language about anterolisthesis, spondylolysis, central canal stenosis and foraminal narrowing. Id. But Blake did not offer a diagnosis of spinal cord damage or myelopathy, and he did not ascribe Sutton's pain to spinal cord damage or myelopathy.

MetLife asked Zheng whether the new information changed his opinions. See AR 85758. It did not; as before, he believed, “[t]he information [did] not support the claimant having objective evidence of myelopathy.” AR 858. First, Zheng saw no clinical signs of myelopathy. Id. Second, he cited the 2021 MRI report and its statement that the MRI had revealed “no significant central canal stenosis.” Id. Third, Zheng wrote “there is no cord” in the area of the spine “where most of [Sutton's] findings are located.” Id. “[T]his is the level of the cauda equina,” he explained, “not the myelon.”^[6] Id.

MetLife sent Zheng's updated assessment to Sutton's counsel. AR 848. Counsel contended MetLife had required more evidence from Sutton than the plan actually demanded, AR 832-33, and he pointed out that Sutton's symptoms-such as pain, numbness, and absent reflexes in his legs-could be attributable to myelopathy, AR 833-34. MetLife referred the case to Zheng once more. See AR 821-23. Zheng stood by his opinion that Sutton had not identified any objective evidence of myelopathy. See id. Zheng dismissed Sutton's reports of pain and numbness as subjective. AR 822. He found the MRI and x-ray reports unenlightening; they did not “confirm” the “spinal cord itself' had been “impacted.” Id. The same was true of reports that Sutton's leg reflexes were absent. “Absent reflexes do not suggest myelopathy by themselves, and lower extremity reflexes can disappear with age itself.” Id.

In light of these opinions, MetLife upheld its decision to deny benefits beyond twenty-four months, citing a lack of “objective evidence” of myelopathy. AR 803-07. Sutton then filed this case. See generally Compl., ECF No. 1. MetLife has lodged the administrative record, and the parties submitted full trial briefs. See generally Pl.'s Br.; Defs.' Br.; Pl.'s Resp., ECF No. 31; Defs.' Resp., ECF No. 32; Pl.'s Reply; Defs.' Reply, ECF No. 35. The court held a bench trial on the administrative record on June 30, 2023. Michael Horrow appeared for Sutton, and Robert Hess appeared for MetLife.

II. LEGAL STANDARD

ERISA permits a plan participant to file a lawsuit in federal district court “to recover benefits due to him under the terms of his plan.” 29 U.S.C. § 1132(a)(1)(B); see also Metro. Life Ins. Co. v. Glenn, 554 U.S 105, 108 (2008). When a plan participant contends benefits were wrongfully denied, a federal court ordinarily reviews the denial “de novo.” See Metro. Life, 554 U.S. at 111; Abatie v. Alta Health...