Judge Gertner of the federal district court in Massachusetts issued a pair of bookend decisions in long term disability cases a few days back that present an interesting contrast with regard to an issue that troubles many critics of the arbitrary and capricious standard, namely the extent to which an administrator deciding a claim for benefits can favor the opinions of its own reviewing physicians over the opinions of the participant/claimant’s treating physicians. In the first decision, in the case of Sorenson v. Metropolitan Life, the judge sets forth, and then finds in favor of the plan to a large extent based on, the general rule, which is, in the court’s words, that:
The law permits a plan administrator to rely on the opinions of a non-examining, reviewing doctor like Dr. Schroeder, see Tsoulas v. Liberty Life Assurance Co. 454 F.3d 69, 81-82 (1st Cir. 2006), and does not require that the opinions of treating physicians be given special weight, see Leahy v. Raytheon Co., 315 F.3d 11, 20 (1st Cir. 2002). To the extent that the reviewing and treating physicians offer conflicting opinions, the plan administrator has the discretionary right to choose between them, so long as its decision is reasonable.
However, in another decision issued the same day – Taylor v. Metropolitan Life – the court imposes, and bases its decision in favor (this time) of the participant/claimant on, certain limitations on that principle, finding that:
While MetLife is not required to give deference to treating physicians, see e.g., Vlass v. Raytheon Employees Disability Trust, 244 F.3d 27, 30-32 (1st Cir. 2001), Doyle, 144 F.3d at 186-87, it is unreasonable to selectively reference that physician’s notes and fail to address the sections of her submissions most relevant to the claimant’s ability to work. A plan administrator "may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician."
ERISA litigation, even LTD cases governed by the arbitrary and capricious standard, is not close to the locked in, pro-administrator structure that many critics of ERISA claim it to be. Rather, as the interplay of these two cases show, there is unquestionably a yin and yang to the case law and to the controlling standards, that tries to find the right balance between the authority of the administrator and the rights of the participant.