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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.”
Continue Reading MetLife improperly dismisses evidence of radiculopathy and limits benefits under 24-month Neuromusculoskeletal limitation in LTD Policy

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.
Continue Reading Dell & Schaefer Disability Attorneys Discuss Winning LTD Benefits on Second Appeal to MetLife and the Importance of Medical Documentation

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.
Continue Reading If You Are Aware of an Underpayment or Miscalculation of Your LTD Benefits Don’t Wait to Hire an Attorney because Your Time to File a Lawsuit May be Running Out

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) 

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