MetLife seems to be committed to finding a way to deny your claim even after you have received a letter telling you your claim has been approved and you will receive benefits for “x years” or “until you reach the age of 65.” The company leaves out the caveat that they will be frequently monitoring your medical condition, looking for a way to deny you further benefits.

At Dell & Schaefer, our disability insurance attorneys offer you tips about how to prevent the denial. This means providing strong medical documentation that you are still disabled, educating your doctors on how to document your limitations and restrictions, and when to attach additional information to the Physician Statement form.

GREGORY DELL: Hi. I’m attorney Gregory Dell here with attorney Stephen Jessup. And Steve, today we’re going to talk about a very popular topic for people that watch our videos, which is, how do I protect my disability benefits if I’m on claim with MetLife? And this video is obviously going to be featured on MetLife because every disability policy has its own nuances and every carrier’s policy has differences.

So you know that we represent tons of people on a monthly basis to help them with their MetLife claim, and that’s a service that we offer where we monitor the claim. Every aspect of communication comes to us, and we’re continually advising clients as to what needs to be done in order for their benefits to be protected. So first off, explain why people think that, if they get approved for benefits with MetLife, that it’s going to stay forever. How does the internal process work? Do they get approved and that’s it, or how is the claim evaluated on an ongoing basis?

STEPHEN JESSUP: Well, like we’ve discussed in the past, there’s no such thing as a permanent disability with the disability carrier, meaning each month technically that they are sending out your benefit, they’re making a determination, are you disabled that given month? While they’re doing the administering the claim, they’re always going to be constantly doing extra reviews, new reviews on things.

So even though you’re on claim and they may say, oh– a lot of the award letters will say, your benefits will continue to X and such date, which is usually age 65– and people think, oh, that means I’m just going to continue to get paid, but there’s that caveat with, as long as you meet the provisions of the policy. And therein, one of the big things is the provisions of your policies and how MetLife’s going to use that to set your claim up for a denial.

GREGORY DELL: Right. Because every day, someone goes, I don’t understand. They told me my benefits go through 2034. Why are they asking me for more information? Why are they threatening to deny my claim? But obviously, it’s because month-to-month requirement– and on the simplest level, the person administering the claim at MetLife has to report to somebody or to their computer system, and the checks aren’t on auto-pay.

So that person has to manually review the file every month, possibly get approval, and then issue the checks. And hence, that leads to, what you need to do to be prepared every month? So let’s start with the single most important thing in order to keep your benefits protected with MetLife. What comes to mind for you?

MetLife Requires Continuous Medical Treatment with Supporting Strong Medical Records

STEPHEN JESSUP: Surprisingly– this would seem like common sense– going to your doctor– a lot of people, when they get on claim– there’s really nothing my doctor can do for me, so they may only treat like once every six months. Now, if you’ve been on claim for an extended, extended period of time, that may fall under this idea of appropriate care, but for a lot of people– especially if they’re going to– early on going to be sent you claim forms for your doctor to complete every month, every two months, and requesting updates, treat with your doctor.

And then that leads into making sure the doctor’s documenting any complaints that you’re having, any changes in medication– that those records are good. But first thing they’re going to look at, is is there any new medical? And if there isn’t, that’s going to trigger them to do their own internal medical reviews to see, honestly, if there’s a way that they can deny the benefit– that you’re at a level where they think you’d be able to work.

GREGORY DELL: So how do you, Steve, go through the process of telling your clients how often should they be going to the doctor?

STEPHEN JESSUP: It’s going to really be based a lot on the specific medical condition that they have. Ideally, a doctor is going to give you an idea of appropriate care. You would ideally like to see every two to three months that they’re in with the doctors. If they’re treating with multiple doctors, then– I have some clients that are seeing three or four doctors a month, just depending on what the condition they’re treating them for– but if you only have one doctor you really need to be making it, in my opinion at least every 60 to 90 days at the most, or you will have some issues with the insurance company.

GREGORY DELL: I see commonly that claimants say, my claim was denied. MetLife’s claiming that the medical records don’t support my restrictions or limitations. When you then, Steve, subsequently get involved with the claim, and you get the claim file, and you look at the medical records, what weaknesses do you see in the medical records that could have been avoided to keep that person on claim?

STEPHEN JESSUP: I think it comes down to the way medical records are kept now electronically. They’ll go through a series of check the box – do their basic exam. Some doctors don’t do that, and there’s a default that there’s no issue. Or I’ve seen it where they’ll cut and paste the same exact portion in each subsequent medical record, not really indicating any improvement.

You’d maybe have to look very hard to see in the last line that they recommended updated testing or changed out a medication, so you want to make sure that those records are really supporting it. If you have range of motion issues, or complaints of pain, and various physical ailments or restrictions, you want those records to say it. And sometimes you get this problem too where they’re doing on the, you know, check the box type thing.

It says, general exam– fine– but then it’ll go later and it’ll say, had issues with movement in the right side of the body– whatever the case may be. But MetLife’s going to hone in on that fine, unremarkable, no change. Or one catch that they love to use as if the medical record says that they’re doing better, that there’s been some type of improvement. Now, ideally, that’s the purpose of medical treatment.

GREGORY DELL: Right.

STEPHEN JESSUP: If you’re not working and you’re getting your treatment, you should be getting better, but you don’t want to look great on paper. Better compared to how you were is still bad, but MetLife will only see better.

GREGORY DELL: You brought up two things. One was doctors wanted document improvement, but then MetLife jumps all over the claim and goes, oh, I see you’re getting better. Let’s talk about a return to work strategy– which is ridiculous, but doctors don’t want to always document the negative. The other thing that I wanted to bring up was, how do you coach, guide, educate the clients to get their symptoms into the medical records? What tools can they use when approaching the doctor so that the doctor knows that this is a disability claim, and not just another patient who’s treating?

You Need to Educate Your Doctors on How Your Medical Records and their Physician Statement Forms Should be Drafted to Meet MetLife’s Claim Approval Requirements

STEPHEN JESSUP: I think one of the big and most important things is going to be the relationship that the person has with the doctor. If this is a brand new doctor– and a lot of people are usually worried to say, hey, how do I just let them know I’m on disability? I don’t want them thinking that’s what this is about. But if it’s a doctor we’ve had established care with– which is typically the case– I think you just have a very honest conversation with them.

And it’s important to convey to the doctor too that disability for purposes of the policy you get through your employer doesn’t mean you’re disabled from activities of daily living and leading a normal life, if you will. It’s really this idea of not being able to do your occupational duties, or if you’re at a certain stage– 24-month stage– gainful occupations with reasonable continuity– so having that conversation with them.

A lot of times too, people complain that they don’t get a lot of time with their doctors. It doesn’t hurt to bring in a list of any changes that you’ve had, notes, problems that you’re having. People keep pain journals, headache logs, things like this. Give it to the doctor. And they ask, hey, can you make this part of the record? And it gets brought into the medical so, when they do see it, it’s at least touched upon in there and the doctor has that to go back on.

Because if the doctor gets a cold call from insurance company doctor, they’re going to look at their file, and they may only be looking at their records and not have a recollection of everything, but if they see stuff that you’ve added and provide to them, it can trigger memories are getting more frame of reference of what they need to discuss with MetLife’s doctors.

GREGORY DELL: Right. I think the bottom line is you have to be proactive with the doctor. You have to let the doctor know that you have a disability claim and make sure that the doctor understands that everything the doctor’s doing can be detrimental to your claim if it’s not done the right way– so to go over and over the additional information beyond what they usually do, because MetLife’s going to request those records with or without your knowledge.

And if they’re not complete, they’re just going to say the records don’t support your complaints, and they’re going to deny the claim. That’s 9 out of 10 denials that we see. The next area, Steve, I want to talk about is the claim forms, and why, when we submit claim forms, we don’t just rely on the limited space that MetLife typically provides in their claim forms.

To Meet MetLife’s Requirements, Your Physicians Need to Provide More Information than is Provided for in the Limited Space on the Physician Statement Forms

STEPHEN JESSUP: Well, the claim forms are set up to– honestly, to trick people, trick doctors. They don’t give you a whole lot of room for explanation. Now, there is a definite fine art between sharing too much and giving what’s appropriate. When we’re doing claim forms, you want to stay away from certain words like never– I never do X, Y, and Z, because if they put you under video surveillance and capture it, they’re going to use it against you as attacking your character.

But you need to be able to elaborate what’s going on. If you have barely line’s worth of paper to be able to explain how you’re prevented from doing your job because your medical condition, you’ll never convey it– so attachments to it where you can elaborate, go into more information about specific occupational duties. And then, even when he gets to the attending physician statement, those are pretty generic, but for– if you have a behavioral health condition, that’s more of a specific– just for that.

But anything else, whether it be you have back pain, you have chronic migraines, you have MS, or Parkinson’s, it’s going to be the same general claim form. And that claim form is going to give the doctor limited space, and even limited opportunities to really go in. We’ve seen plenty of times when they’re talking about physical abilities, and the lowest ability on there that they give a doctor an option for is sedentary work– which a vast number of jobs are that.

So a doctor thinking, hey, I’m doing the right thing by giving the highest level restriction is actually checking a box indicating they think you could work at that level. So it’s a matter of making sure that there’s no mishaps on those claims forms and what you’re reporting in those claim forms is consistent with what’s in your records, and also consistent in what you do in day-to-day life, in the event they do put you under video surveillance.

GREGORY DELL: Steve, one of the more important things in the claim form is about the activities of daily living, like you just said. And the reason that’s so important is that people always get super nervous with that question. They think, well, if I tell them I go to a bike– on a bike ride, or if I go to the gym, or if I walk the dog, they’re going to cut me off. It depends how your policy language is. It depends what your occupation was. It depends what your medical condition– depends what your doctor would say about how you answer that question.

So you want to disclose certain things because you want to live a normal life, but at the same token, you have to be careful in how you do it. And that’s how we always advise the claimants on an ongoing basis– that disclosure is good, because we want you to live a normal life. You don’t have to be in bed. You don’t have to be confined to the home to continue to get paid benefits by MetLife, but you also have to walk that line.

Dell & Schaefer Provide a Monthly Claim Handling Service Designed to Prevent MetLife From Denying Your Claim

I can’t give the exact answer as we sit here, but it’s certainly better to put these things out there than to let them see you on video, like you were saying. So the service we offer, where we monitor the claim– everything comes to us, and what’s really unique about it is that we offer the service on a flat fee basis, where we charge a small percentage of the monthly benefit on an ongoing basis, and it becomes our responsibility to make sure that you’re maintaining your medical treatment, that the checks are coming in on a timely basis, that the medical records continue to be strong, and being available at all times to answer any and all of your questions, as well as being available for you when MetLife wants to do an interview, or have someone come to see you, or set you for a medical exam.

We’re always going to prep you for all these things, and everything’s included with our flat fee. Now, Steve, on the individual disability claim, the non-ERISA claims, you know that MetLife’s one of the few companies that every month, they want a claim form.

STEPHEN JESSUP: No matter how long you’ve been on claim–

GREGORY DELL: And so that’s– can be kind of annoying, and that’s just, again, further proof that every month, they’ve got a punch a button, look at a claim, or do something. And unfortunately, MetLife has more turnover than some of the other disability insurance companies. And you get a new claims person on the claim, and you’ve got a file that’s thousands of pages big, and the new claims person may be a little bit lazy, doesn’t want to read through everything, and says, you know what– this is a decent-sized monthly benefit.

Let me send this person out for an independent medical exam or a compulsory medical exam, and it starts all the problems– as opposed to, when you have a lawyer involved, I think they’re more like, wait a second. I see there’s a lawyer here. I’d better be cautious and watch what I’m doing, because this person’s going to be protected at every step.

So that’s a big advantage to having a lawyer. So if you have a claim with MetLife and you’re currently on claim, no matter what stage you’re at– whether it’s myself, or Stephen, or any of our disability lawyers– we’re able to help you with your claim. We’ll provide you with an immediate free consultation, which is a telephone consultation. Our clients are located all over the country, and we look forward to the opportunity to speak with you.

Our disability insurance attorneys at Dell & Schaefer offer a monthly claim handling service that takes the pressure off you. All communication from MetLife goes through us. We are proactive and take steps to ward off a denial by preparing months in advance for events like when the definition of disability changes from being unable to perform the duties of your own occupation to being unable to perform the duties of any occupation for which you are trained, educated, or otherwise qualified.

No matter where you are at in your claims process, and no matter where you live, contact us for a free phone consultation and we will let you know if we can help. Call us at 800-411-9085.