MetLife long term disability policies are notorious for containing very restrictive 24 month limitations for medical conditions that they classify as a neuromusculoskeletal and/or soft tissue disorders. The limitation typically limits benefits to two years for disabilities caused by neuromusculoskeletal and soft tissue disorders, “including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue.”

However, the limitation is inapplicable if the claimant has objective evidence that establishes the presence of at least one of six exceptions, including radiculopathy which MetLife policies typically define as “Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.”

In a recent case decided by the 7th Circuit Court of Appeals a long term disability claimant claimed she suffered from a radiculopathy but MetLife refused to recognize her evidence.

The lawsuit was filed by Susan Hennen against MetLife to recover long term disability benefits that had been terminated at the 2 year mark using the neuromuskuloskeletal limitation. Hennen’s medical history included multiple back surgeries dating back to 2008 and although she was able to work following those surgeries she suffered another injury that forced her to stop working and file a claim for disability benefits under her employer sponsored long term disability policy.

Evidence of Radiculopathy not enough for MetLife

She had multiple doctors supporting her claim including her principal doctor who reported Hennen’s inability to work due to post-laminectomy pain syndrome and lumbar radiculopathy. The doctor’s opinion was supported by an MRI which showed an annular fissure but no nerve compression. Despite the doctor’s opinion, MetLife denied the claim forcing Hennen to appeal. On appeal, Hennen submitted a recently performed EMG which revealed nerve-related abnormalities the examiner concluded to be confirmation of radiculopathy in four nerve roots. However, the doctor acknowledged the findings could be due to a different nerve disorder.

MetLife’s medical director acknowledged the EMG diagnosis of radiculopathy and although the examination took place after benefits had ended he found it reasonable to conclude the radiculopathy was present before the benefits ended.

Following the medical director’s review, MetLife sought a medical opinion as to Hennen’s functional capacity from Dr. Neil McPhee. Although Dr. McPhee was asked to focus on functionality he disputed the diagnosis of radiculopathy and concluded the test was “negative for active radiculopathy.” He otherwise concluded that Hennen’s chronic pain and medical history limited her ability to work.

MetLife ignores its own medical director’s opinion

Based on Dr. McPhee’s unsolicited opinion regarding the radiculopathy diagnosis MetLife decided to ignore its own medical director’s opinion and deemed the 24 month limitation applicable due to “a lack of objective proof of radiculopathy. Ms. Hennen’s treating doctor disagreed arguing that the “EMG study results prove, without any doubt, that the patient suffers from radiculopathy.” Dr. McPhee responded that he disagreed and maintained his opinion but also stated that additional electrodiagnostic testing would be helpful as well as an independent medical examination by a physical medicine and rehabilitation specialist or neurologist whose training and practice includes electromyography.

Despite the doctor’s recommendation, MetLife upheld its decision the day after receiving the addendum report from Dr. McPhee.

A lawsuit ensued. Unfortunately, Ms. Hennen lost the case at the district court level but won in the court of appeals.

The court of appeals was not happy with MetLife’s unreasonable decision to ignore its own medical director’s opinion and Dr. McPhee’s recommendation for additional testing and examination to settle the dispute with the treating physician. The court criticized MetLife’s reliance on the opinions of Dr. McPhee and unsupported decision to ignore the opinions of 4 other qualified doctors including MetLife’s own medical director. While the evidence of radiculopathy was not conclusive, the number of credible doctors who agreed that radiculopathy was supported could not be ignored.

Court remands the case back to MetLife for another review

Rather than overturning MetLife’s decision, the court concluded that MetLife should not have concluded its review without considering the doctor’s recommendations and so remanded the claim back to MetLife for a review to include those recommendations.

While this case represents a “win” for the claimant, the court’s decision did little if anything at all to punish MetLife for its unfair assessment of Ms. Hennen’s claim. Ms. Hennen will have to endure another review by MetLife.

Ms. Hennen’s case is important for future claimants fighting MetLife over the neuromusculoskeletal limitation based on alleged radiculopathy. Radiculopathy is often tough to prove but this case at the very least shows that radiculopathy may be established without a positive EMG or MRI. Also, insurance companies are not free to disregard a consultant’s recommendation for additional testing or examination.

This case was not handled by our office, but we think it can be beneficial to those receiving MetLife disability benefits based on a condition that falls within the neuromusculoskeletal limitation. If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.