When MetLife Insurance Company dishes out a denied disability claim, it’s crucial that your initial appeal is comprehensive and convincing. That’s because you only get one shot at it. Disability insurance lawyers Greg Dell and Alex Palamara, who have handled more than 1,000 of these MetLife claims, explain what’s involved in the process and what it takes for a successful ERISA appeal.
Though individual MetLife disability policies do exist, resulting in an occasional private disability denial, the vast majority of MetLife disability coverage (about 95 percent) comes through group policies. Once you’ve received a disability insurance claim denial from MetLife on one of these policies, the burden falls on you to file an appeal. Whether you choose to go it alone or let a seasoned expert from a disability law firm handle it for you, there are some absolutely essential things that must be in that appeal.
Disability insurance attorney Alex Palamara explains that ERISA laws governing group disabilities are very tough laws, and they “pretty much favor the insurance company.” But most importantly, your appeal after a denial is the one and only chance you have to get documentation into your claim file. Even if other proof of your disability comes up later, you will not have the ability to add that information into your claim file
Goals of an ERISA Appeal
When filing an ERISA appeal, you basically have two goals, according to Alex Palamara. One purpose of the appeal to get back on claim by having MetLife reevaluate the information and reinstate your claim. The next goal when appealing the denial is to strengthen your case for a lawsuit down the road. Remember that when disputing the ERISA denial in a court of law, the claim file from your original appeal is still closed for new documentary evidence.
“Once the final denial is issued, that claim file is closed and no more information can be submitted to the judge,” Alex Palamara stresses. That’s why it’s so important to get it right in your initial appeal of the denial.
How Does the Appeals Process Move Forward?
If you choose to have a disability insurance law firm handle the claim denial and appeal it on your behalf, your attorneys will first send a letter requesting the claim file, which legally has to be released in a timely manner. That file contains all information that MetLife used to deny your claim, and it can be 500 pages long or even many thousands of pages. Your lawyers will be looking for the proverbial “needle in a haystack” – or in this case, several needles. Somewhere buried in that thick imposing file, which will likely be cryptically disorganized, are the following crucial pieces of information.
- An “independent” physician consultation. They could easily have ordered a consultant review in which they sent your medical records to a doctor or nurse of their own choosing. They are seeking to obtain an evaluation that is inconsistent with your own treating physician’s diagnosis. This part of the claim file could be up to six or seven pages long out of a 5,000-page file.
- Independent medical evaluation. MetLife may have required you to submit to a new medical evaluation, resulting in a “functional capacity evaluation” by their own chosen professionals.
- Surveillance. It’s entirely possible that MetLife will have conducted surveillance of you that is recorded on video. A CD or similar type of recording will be in the claim file, and your attorney will review it to look for discrepancies or exaggerations in the written account they’ve inserted into your file.
After a thorough review of the documentary evidence used to deny your claim, the seasoned and skillful disability insurance attorneys at Dell & Schaefer will be able to identify what the insurance company used to deny your claim. And that’s when the real work begins.
Your own personal treating physician throughout your period of disability is a critical link in the appeals process. Your new attorney will reach out to the doctor and other treating medical professionals to get their input on what is in the claim file and to make sure they understand the criteria for a legitimate disability. Creating a new physician statement to accurately reflect your true condition is the ultimate goal here.
The new customized attending physician statement, which will be drafted by the law firm, contains pertinent and detailed information that’s particular to the client’s claims, including the identification of physical restrictions and limitations, and an opinion of the ability to do either their job or any job.
“We draft attending physician statements for each of our clients,” states Alex Palamara, “because every single client’s condition is a bit different… Anyone could be suffering from fibromyalgia, but there’s always different variances for each client.”
It’s also important to get objective evidence rather than just medical opinions, adds attorney Greg Dell. For example, if someone has a neck or back problem and is complaining of radiating pain, the objective evidence of functional limitations could include an updated MRI, C.T. scan, EMG test or nerve conduction study. A claimant without a representative attorney who knows what the insurance company is looking for would not likely get this often-pivotal and irrefutable evidence.
The Vocational Component
Finally, the last thing to include in an effective ERISA appeal is the vocational/occupational component. With group disability polices such as ones by MetLife, the definition of disability generally changes after a certain period of time. During the first 24 months, the focus is on the ability to perform “your own” occupation. But after 24 months, explains Alex Palamara, it gets a bit more complicated. At that point, you must prove that you are unable to perform “any occupation.”
In the first phase, insurance companies will often take great liberties in interpreting a claimant’s occupation. They’ll look at a dictionary of standard occupational titles and make their own assumption of whether your medical issues preclude you from performing “your own” occupation.
In the next “any occupation” stage, companies such as MetLife will strive to prove that you are capable of performing other occupations, especially ones deemed “sedentary.” However – and this is important to know – there is an income component that comes into play when determining what kind of work you are capable of performing. The insurance company must be able to show that any job they claim you are capable of doing compensates you at 60 percent or 80 percent of your prior monthly earnings.
A vocation expert, hired by your disability insurance attorneys, can provide invaluable input on explaining the job requirement and duties of the claimant’s “own occupation.” They can also apply it to any occupation stage and then pinpoint jobs that the disabled person could or should be able to perform based on his or her restrictions and limitations.
Other vocational components of the ERISA appeal include a market labor analysis for available jobs, as well as a collection of statements from past coworkers and family members. These all go into the appeal as collective proof that your disability claim denial should be overturned.
Where to Go from Here
Now that you are familiar with how the process works, it’s time to move forward in a positive way toward final resolution. A disability insurance lawyer at Dell & Schaefer can put you in the best position to win your claim in any part of the country. They always offer a free consultation, so just click the free consultation button on the Dell & Schaefer website, or call for a direct conversation. They’ll review your denial letter right away and let you know how they can help.