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.”

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In this video, disability attorneys Gregory Dell and Victor Peña talk about a case won by Mr. Peña in a second appeal for a man who suffered with back and knee injuries as well as carpel tunnel syndrome. The man claimed he was unable to work in his own occupation which was classified by a vocational assessment as a light-duty occupation.

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In Riley v. MetLife, a case decided in March 2014 in the United States Court of Appeal for the First Circuit, Plaintiff Riley first made a claim for LTD benefits in 2000 when he was employed as an associate general manager. He received LTD benefits, but returned to work in 2001 in a non-managerial position where he earned substantially less. In 2002, Riley left work once again and made another claim for LTD benefits. Riley’s LTD claim was eventually approved in 2005, and he received his first LTD benefit check in April of 2005 for an amount based on his non-managerial salary, which was substantially less than he would have received based on his managerial salary. Since Riley disputed the amount of his lower LTD benefits based on his non-managerial salary, he refused to cash the checks and threatened to file suit.

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As we have indicated time and time again, an ERISA administrative appeal is one of the most important documents to be filed as part of your disability insurance claim. Second only to the initial application for benefits, your administrative appeal is often your only opportunity to provide evidence of disability sufficient for an insurance carrier to overturn a denial of benefits. Although some insurance carriers such as Lincoln require a mandatory second appeal and others such as Prudential and Cigna allow for voluntary second appeals, the vast majority of insurance carriers only allow for one level of appeal and if that is denied the only recourse available is to file a lawsuit under ERISA. We have explained the perils of litigating an ERISA based disability policy on many occasions on our website, as such, in this article so we will not go into the Arbitrary and Capricious standard of review commonly applied in ERISA cases. However, it is important to note that in a lawsuit brought under ERISA there are no jury trials nor is there live testimony at “trial,” which means neither you as the insured or your doctors will be allowed to testify before the judge, and last, relevant to this article- no new information after the final denial of benefits will be allowed at trial. With this final caveat, it becomes all the clearer why filing as complete an Appeal as possible is crucial to receiving your disability benefits.

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In Stupar v. Metropolitan Life Insurance Company (MetLife), plaintiff, an icer with the Kroger Company, received 24 months of long term disability benefits due to her diagnoses of post-traumatic stress disorder (PTSD), major depression, panic and anxiety disorder. At the end of the two-year period, MetLife terminated her benefits on the grounds that she was limited to 24 months of benefits under the Mental or Nervous Disorders clause of the policy. She objected, exhausted her administrative remedies, then filed this ERISA lawsuit.

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Kresich v. Metropolitan Life Insurance Company (MetLife) is a federal case out of the Northern District of California favorable to a plaintiff who was harassed, accused of lying and oppressed during the processing of his disability claim. Because of MetLife’s conduct, the plaintiff sued for intentional infliction of emotional distress (IIED). Despite MetLife’s vigorous argument that the claim was preempted by ERISA and the plaintiff could not pursue his tort action, the court disagreed and found in favor of the plaintiff. Relying on precedent, the court stated “Plaintiff’s IIED claim stems not from the handling and disposition of his claim, but from independent allegations of harassment and oppressive conduct. There is no alternative enforcement mechanism under ERISA by which Plaintiff could bring such a claim.”
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