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Metlife’s wrongful denial of long-term disability benefits to a Wells Fargo employee is reversed

Many employees rely on disability insurance benefits if they have been injured or have developed a sickness which prevents them from working.  Disability insurance provides individuals with a percentage of his or her typical salary until the employee is able to return to work or turns age 65. However, what employees aren’t usually aware of is that as soon as disability benefits start, the disability insurance company wants them to stop – and they will use a wide range of tactics to make that happen.

As an attorney who has worked on thousands of long-term disability claims against major insurance companies around the country, I can tell you that insurance company tactics can involve undercover investigations, fact-twisting, and even having bias doctors subjectively determine that you are not disabled  as in a recent disability insurance case.

Graciella Saffon vs. Wells Fargo

Graciella Saffon, an employee of Wells Fargo Bank, had suffered from degeneration of her cervical spine for several years. This condition was confirmed by several MRIs, X-rays and other medical information. In 2001, Saffon was in a car accident which aggravated her neck condition, leading her to quit her desk job and apply for long-term disability benefits with MetLife. After a certain amount of time, the insurance company began paying Saffon long-term disability.  However, a year after she began receiving these long-term benefits, MetLife stopped paying them, informing her that she no longer met the terms of disability.

How MetLife Worked to Deny Mrs. Saffon Her Long-Term Disability Benefits

MetLife hired two different doctors to look over Saffon’s medical records, resulting in the following statements.

The first physician, Dr. Thomas, stated that “Saffon’s file lacks clear sequential, detailed and objective clinical information, which would completely preclude Ms. Saffon from an attempt to return to work.”

After Dr. Thomas’s file review, MetLife stopped the long-term benefit payments. Saffon appealed MetLife’s denial and provided an updated cervical MRI with additional medical records.  A letter from her neurologist, Dr. Kudrow, was also included, stating that she had undergone various pain treatments which were ‘without sustainable benefit’ and that she was unable to remain in a sitting position for more than a few minutes at a time.

Following the submission of the Appeal, a second doctor, Dr. Menotti, looked over Saffon’s records and claimed that her reports of headaches and chronic pain syndrome were not enough to keep her from working. MetLife then stated that Saffon had not supplied them with a functional capability evaluation so they were unaware of her ability to function at work. The appeal was denied.

Mrs. Saffon sued MetLife in California District Court, seeking back-payment of her disability income benefits. The District Court affirmed MetLife’s denial, and Mrs. Saffon continued her battle for disability benefits by filing an appeal with the 9th Circuit Court of Appeals. After reviewing the case, Judge Kozinski determined that MetLife had not given Saffon’s case a full and fair review for the following reasons:

Judge Kozinski remanded the case back to the California District court, requiring that they give a full and fair look at Mrs. Saffon’s case taking into account the flaws in their review process and the ERISA laws. This was a victory for Ms. Saffon, who was given a second chance to show that she most certainly did deserve disability benefits due to her inability to work. However, one has to note that Mrs. Saffon did everything she could to show this in the first place, and had MetLife acted reasonably, Mrs. Saffon would not have had to go without her disability benefits or go through a painful and drawn out battle in court at all.

There are 4 opinions so far. Add your comment now.

Larry Brixey:

I was just denied long term disability by MetLife due to a preexisting condition that has nothing to do with the reason I was off from shoulder surgery. I have been off work for 15 months from having 2 shoulder surgeries. They said that they made this determination due to my pharmacy records and prior medical conditions. They are refusing to pay me the $4400.00 per month they said they would pay me up to the age of 65. I’m 54 at this time.

Attorney Stephen Jessup:

Larry,

Please feel free to contact our office for a free consultation to determine how we may be able to assist you in filing an appeal of the denial of benefits.

Kim:

My name is Kim, I am a recruiter at Wells Fargo for 10 months. I started making many mistakes at work and became very concerned. I went to my physician for a check up in July 2013 and let her know of the mistakes I was making and also let her know that while driving I got lost. She sent me to a Psychologist for testing and she said I had a small stroke and wanted me to not work until January 15th 2014 when she would re-test me. She referred me to a neurologist who sent me to a Psychiatrist who determined I was very depressed and he changed my medication and did a round of ECT treatments. He said I should apply for Social Security benefits. I do see a therapist twice a week as well. I find it very difficult to leave my home. I don’t sleep much and I am severely depressed with anxiety.

Wells Fargo did pay me short term disability from July until 1/6/14. I did pay for long term disability through payroll deductions as a benefit. I was denied long term disability because they said this was a pre-existing condition. My mom died in 2004 and I started taking Cymbalta. Please help me if you can, I am very afraid and destitute.

Attorney Stephen Jessup:

Kim,

Your case will be heavily dependent on the pre-existing language contained in your company’s policy. I would suggest getting a copy of the policy if you don’t already have one. Please feel free to contact our office to discuss how we may be able to assist you.

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