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.
Continue Reading Court Rejects New Information in ERISA Disability Case

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.
Continue Reading MetLife Properly Limited Plaintiff’s Disability Benefits Under the Mental/Nervous Limitations Clause

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.” Continue Reading California Judge Allows Lawsuit for Intentional Infliction of Emotional Distress Due to Manner in Which MetLife Investigated Disability Claim

Quite often, insurance companies create a maze of entities that could confuse the most cautious policy holders. One entity may own the fund. Another entity may administer the fund. So who should a plaintiff sue when these corporate entities conspire to break a promise to pay disability benefits? Fortunately, skilled disability lawyers know these insurance company tricks and can figure out who is ultimately responsible for a wrongful denial of disability benefits. Sometimes, it depends on bringing the right claim against the right party.

The case of Franklin v. AT&T Corporation is a prime example. The plaintiff worked at AT&T as a systems analyst for eleven years. She had long-term disability benefits under the AT&T Long Term Disability Plan for Management Employees ("the Plan") that were administered by Metropolitan Life Insurance Company ("MetLife’). Sedgwick Claims Management currently handles all AT&T disability claims. In 1999, the plaintiff filed for and received the long-term disability benefits arising from a number of causes including Crohn’s disease, breast cancer, chemotherapy, chills, night sweats, nausea and depression.

Three years later, MetLife reevaluated the plaintiff’s eligibility for long-term disability benefits. MetLife had demanded that the plaintiff apply for Social Security disability insurance benefits and, when she obtained them, reimburse the Plan for all the social security benefits she received when the Social Security Administration agreed she had been totally disabled since 1999. Soon after cashing the check, MetLife determined that the plaintiff was not in fact totally disabled and stated she could return to full-time work in other occupations. This conclusion led MetLife to deny the plaintiff’s claim for continued long-term disability benefits.

The plaintiff sued, arguing that her long-term disability benefits were wrongfully denied by MetLife and the Plan. Both defendants filed a number of motions. MetLife challenged the plaintiff’s ability to hold the insurance company accountable for its role in denying coverage because AT&T had fired MetLife as the plan administrator more than a year and a half before the plaintiff filed suit. The Plan claimed that the denial was within its discretionary authority.

The Court Awards Disability Benefits for What MetLife Did

A federal court in Dallas ruled that the plaintiff was entitled to long-term disability benefits and that MetLife was entitled to be dismissed from the lawsuit as it was merely the administrator. The plaintiff could only recover the disability benefits from the Plan because it had not brought a claim against MetLife for breach of the duty of good faith and fair dealing, which requires Texas insurance companies to treat policy holders in a certain manner. Nonetheless, MetLife’s actions were the central focus of why the court held the Plan responsible. The court specifically noted:

  • MetLife had distorted the opinions of treating physicians when it characterized the plaintiff as able to return to full-time work;
  • MetLife had not given adequate consideration to the determination for Social Security purposes that the plaintiff was totally disabled; and
  • Though relying on the availability of leave under the Federal Medical Leave Act to claim that the plaintiff could be absent from work to accommodate her illness, MetLife failed to recognize that, as a new employee, the plaintiff was not eligible for leave under the FMLA for twelve months.

While MetLife wasn’t financially responsible to the plaintiff in this case, other companies may think twice before employing MetLife as a plan administrator in the future. The federal court held that MetLife had "cherry-picked" facts in the administrative file to support its position and, for this reason, MetLife had acted in an arbitrary and capricious manner. These wrongful actions persuaded the federal court to order the Plan to reinstate the plaintiff’s long-term disability benefits. Ironically, the plaintiff could have prevailed against MetLife as well (above and beyond the disability benefits recovered against the plan) had the plaintiff’s lawyer brought a claim for breach of the duty of good faith and fair dealing.

Franklin v. AT&T Corp., No.03:08-CV-1031-M, 2010 WL 669762 (N.D. Tex. Feb. 24, 2010) 

Disability Blog & Cases:
California Federal Court Finds That MetLife Abused Its Discretion And Awards Financial Analyst Long-Term Disability Benefits

Shelia W. and her California disability lawyer prevailed in a lawsuit against MetLife when the United States District Court of the Southern District of California found the insurer to have abused its discretion when it terminated Shelia’ disability benefits under the “own occupation” standard.

Disability Blog & Cases:
Sun Life Pays Disability Benefits For Three Years To A Claimant Who Wasn’t Actually Covered Under A Sun Life Policy

In the case of Pamela P. v. Sun Life and Health Insurance Company, the court record shows that Pamela P. applied for long-term disability benefits under an employee benefits plan that was maintained by Los Padres Bank for its employees and was awarded disability benefits for over three years. Said plan was underwritten by Sun Life with its Group Certificate governed by ERISA (the Employee Retirement Income Security Act)…

Disability Blog & Cases:
Another Cigna Hired Gun Doctor To Be Exposed!

Utah Court Wants To Know Relationship Between Dr. Carol Flippen and Cigna Life Insurance

Disability Blog & Cases:
New York Federal Court Denies MetLife’s Motion To Dismiss Lyme Disease Victim’s Petition For Disability Benefits

In the case of Karen N. v. Metropolitan Life Insurance Company et. al, the United States District Court of New York, after hearing arguments from both sides regarding MetLife’s Motion to Dismiss the case, denied the motion in its entirety and directs the parties to appear for a status conference to determine how and when the case will proceed. And, while the Court did deny the insurer’s motion, that doesn’t mean that Karen N. will receive a favorable outcome in her lawsuit to receive her disability benefits. It does mean that the Court believes that the case deserves to be heard and ruled upon once all facts have been established.

Disability Blog & Cases:
Pennsylvania Pharmacy Owner Learns The Hard Way That Accuracy Is Everything When Applying for Disability Insurance Benefits

On January 28, 2011, the United Sated District Court of the Eastern District of Pennsylvania granted Berkshire Life Insurance Company of America’s Motion for Summary Judgment in Michael S. v. Berkshire Life Insurance Company of America, et. al. In addition, the plaintiff’s disability policy and FIO policy were rescinded negating…

FAQ: Social Security Disability Benefits
Can My Disability Insurance Benefits Be Denied If I Am Approved For Social Security Disability Benefits?

Disability Insurance Attorneys Gregory Dell and Cesar Gavidia discuss the misconception that a claimant will be approved for long term disability insurance benefits if social security disability benefits are approved.

Disability Blog & Cases:
Eastman Chemical Company Employee Loses Lawsuit Against MetLife for Disability Benefits

In a case recently decided by an Arkansas Federal Court, MetLife prevailed in a lawsuit filed by an Eastman Chemical Company Employee. Ultimately, due to video surveillance, a lack of medical support, and the fact that the claimant had continued working at a side job (of which he had failed to inform MetLife of) while claiming to be disabled, the Court, it seems, had no choice but to agree with MetLife’s decision to deny Long Term Disability Benefits.

Disability Blog & Cases:
Bon Secours Employee Wins Lawsuit Against Unum who had Denied Him Disability Benefits

A former Engineer Director for Bon Secours, with the help of his Pennsylvania  Disability Attorney, were forced to file a federal ERISA lawsuit after Unum repeatedly denied his claim for Long Term Disability Benefits under a disability policy he was covered under through his employment with Bon Secours. After filing Cross Motions for Summary Judgment, the Court ultimately ruled in favor of the claimant and against Unum.

Disability Blog & Cases:
Do You Know The Job Requirements To Be A Lincoln Financial Disability Claim Specialist?

As a disability lawyer that has handled thousands of disability insurance claims I often wonder about the qualifications and experience of the disability company employee that is making the decision to approve or deny my client’s claim. During our routine activities of watching The Lincoln Financial Group, I came across an internet job posting for an “Associate LTD Benefit Specialist” at Lincoln Financial in Atlanta, Georgia.The qualifications and requirements for the Lincoln benefit Specialist position are also listed at the end of this article.

Disability Blog & Cases:
A Claimant’s View of a Prudential Disability Benefit Denial

We always welcome our clients and other disability claimants nationwide to share their experiences regarding the handling of their disability insurance claim. A client of our law firm that was denied long term disability benefits by Prudential Insurance Company recently posted her thoughts…

Disability Blog & Cases:
Do You Know The Differences Between ERISA Disability Policy And NON-ERISA Disability Policy?

Watch our video to learn more about long term disability insurance claims which are subject to ERISA.

Disability Blog & Cases:
Will A $38 Million Loss Result In More Prudential Disability Insurance Claim Denials?

Prudential is not very happy right now and disability claimants may suffer as a result. Prudential’s group insurance division, which includes long-term disability insurance policies, reported a 2012 first quarter loss of $38 million compared to a gain of $39, million a year ago…

Disability Blog & Cases:
Minnesota Disability Claimant Filed Suit Against Employer Over Terminated Disability Benefits

A Minnesota Federal Court recently ruled against a claimant and in favor of the employer with regards to disability benefits. This case is a poignant reminder that even after being on claim for nearly 7 years, a claimant can be denied at any time. It further shows why it is important to have your claim sufficiently supported with evidence from your treating physician whether the claim administer requests it or not. Let’s take a closer look at the case of Richard P. v. Kohler Co.

Disability Blog & Cases:
Court Finds MetLife Has No Right To Request An IME After Unnecessary Delay

Recently, a claimant was forced to hire a California Disability Lawyer and file a lawsuit against MetLife after being denied continued Long Term Disability Benefits. After agreeing with the claimant that she was disabled through the "own occupation" period, the Court awarded the claimant benefits for that limited time period. However, the court then asked MetLife to take a closer look at the "any occupation" period. For an unexplained reason, MetLife dragged its feet on making a determination.

Connie White waited more than five years to file a lawsuit against MetLife for denial of her disability benefits. The law in Louisiana only provided Ms. White 5 years to file her legal action. The district court dismissed her disability claim and the 5th Circuit court of appeals affirmed the denial. Disability insurance claimants need to take timely action if a claim for disability benefits is denied. Failure to act within strict time lines can result in the inability to pursue a claim in court.

Failing to oppose Metropolitan’s Motion for Summary Judgment, White alleges that her case was decided on the basis of her failure as opposed to the merits of her case. And even though the Court ruled to approve the insurer’s motion, White was given a second chance to file her opposition. White had 10 days to file an opposing position to the original motion for summary judgment. Never filing anything acknowledging the motion, White, after the fact, claimed that the Court erred in its decision to uphold Metropolitan’s decision to deny her long-term disability benefits.

The Fifth Circuit Court of Appeals Agrees to Review White’s Case

As a result of her claim, the District Court of Appeals Fifth Circuit agreed to review the District Courts Summary Judgment de novo. White contended that the Court entered its ruling "solely because Metropolitan’s motion was unopposed." And while the Court disputed this contention, it claimed that it granted the insurer’s motion based on the evidence presented in Metropolitan’s summary judgment motion.

The Fifth Circuit ruled that "the district court’s ruling was correct on the merits." According to the terms of White’s insurance plan, legal action cannot be filed "more than three years after proof of Disability," unless "the area where you live allows a longer period of time to file proof of Disability." In White’s case, she let that time period expire. Consequently, her challenge to Metropolitan’s benefit denial "was filed too late."

Finding of the Fifth Circuit Court in Connie D. White v. Metropolitan Life Insurance Company

The Circuit Court pointed out that since ERISA doesn’t set a specific limitation period, state law applies. In Ms. White’s case the law in Louisiana allows 5 years for a lawsuit to be filed. Unable to present a case that proves that Metropolitan did not materially misrepresent itself or its decision to deny White disability benefits or that "extraordinary circumstances" existed, White did not prevail in her appeal. Consequently, the Fifth Circuit Court allowed the District Court’s ruling in White to stand. The lesson here is that timely filing of disability lawsuits and answers are imperative to a disability claimant’s lawsuit being favourably ruled upon.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-698-9162.