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Beware of Unfavorable Language Limiting the Maximum Pay Period of Neuromuscular, Musculoskeletal or Soft tissue Disorder in MetLife Group Long-term Disability Policies

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Since insurance companies began underwriting and issuing long-term disability insurance policies, they have excluded and limited payments for certain medical conditions. In fact, it is very common to find provisions limiting the pay period – typically to 24 months – for disabilities arising from a mental illness, mostly in group long-term disability policies. As a result of the medical community finally accepting conditions such as fibromyalgia and chronic fatigue syndrome as legitimate medical diagnoses, it has become customary for insurance companies to include provisions which limit the pay periods of these now recognized but difficult to diagnose conditions as well.

However, what is not as common is to find language with extremely broad sweeping scope which excludes a vast number of physical medical conditions which can be proven objectively. I am referring to a provision in many Group Long-term Disability Insurance Policies issued by MetLife, which specifically limits the pay period for neuromuscular, musculoskeletal or soft-tissue disorders to a maximum of 24 monthly payments. Below is what the MetLife limitations provision often looks like:

2. Neuromuscular, musculoskeletal or soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:

– Seropositive Arthritis;
– Spinal Tumors, malignancy, or Vascular Malformations;
– Radiculopathies;
– Myelopathies;
– Traumatic Spinal Cord Necrosis; or
– Myopathies

MetLife Will Claim that the Limitation Provision Limits Common Orthopedic and Neurological Conditions, Such As Degenerative Disc Disease and Herniated Discs

It’s surprising that MetLife can create a long-term disability policy with such unfavorable language, and still convince employers that its product will effectively protect their employees. In 2011, MetLife charged one employer $2,851,540 in annual premiums for a long-term disability policy which contained the limitation provision discussed in this article, and limited other types of conditions as well. Met Life will argue that this kind of limitation provision would limit payments to two years for many claimants diagnosed with conditions such as, Degenerative Disc Disease, herniated discs and osteoarthritis; despite the fact that these conditions can be proven through objective diagnostic testing, such as MRI’s and X-ray’s. It eventually begs the same question asked in Edwin Starr’s 1969 song about war, “What is it good for…?”

Federal Court Finds That MetLife’s Limitations Provision Applies Without Evidence of Radiculopathies

In a recent case out of Massachusetts (not handled by our firm), the U.S. District Court for the District of Massachusetts determined that MetLife’s determination that there was no objective evidence of radiculopathies was reasoned and supported by substantial evidence. In Brien v. Metropolitan Life Insurance Company, 2012 WL 4370677 D.Mass.,2012, MetLife determined that the medical documentation on file contained diagnoses of “nerve pain, back pain/muscle spasm, neck pain radiating to arms/hands, cervical strain, compression fracture [T]11–[T]12, shoulder strain (right), degenerative disc disease thoracic spine, disc bulges, seizure disorder, neuropathy, carpal tunnel syndrome, edema and cervical radiculopathy.” MetLife determined that Brien was disabled due only to the nerve pain, back pain/muscle spasm, radiating neck pain, cervical strain, compression fractures, shoulder strain, degenerative disc disease and disc bulges, which were considered neuromusculoskeletal and soft-tissue disorder, and thus fell under the limited disability provision.

With regards to the remaining diagnoses of neuropathy, carpal tunnel syndrome, seizure disorder, edema and cervical radiculopathy, MetLife “determined that there was insufficient clinical evidence to support restrictions and/or limitations at a severity that would have prevented Mr. Brien from functioning…

The Court concluded that since Brien could not prove that he had objective evidence of radiculopathies (a set of conditions in which one or more nerves are affected and do not work properly causing pain (radicular pain), weakness, numbness, or difficulty controlling specific muscles) MetLife’s determination was reasoned and supported by substantial evidence. The Court enforced the MetLife provision limiting neuromuscular, musculoskeletal and soft-tissue disorders, and limited Brien’s benefits to the 24 months MetLife had already paid.

What Do You Do If You Suffer From a Neuromuscular, Musculoskeletal or Soft-tissue Disorder and You Have a MetLife Disability Insurance Policy?

If you suffer from a neuromuscular, musculoskeletal or soft-tissue disorder and you are insured under a MetLife Long-term Disability Policy, the first thing one should do is review the long-term disability policy, and closely review any provisions discussing “limited conditions”. Second, review all of the letters and correspondence sent to you from MetLife and closely look for any reference to any limitation of benefits provision. Lastly, if you have any questions concerning whether a medical condition is a “limited condition” under your MetLife long-term disability policy, it would not be wise to contact MetLife and discuss the matter with them. You likely won’t get the answer you want to hear. We have reviewed hundreds of MetLife long-term disability policies and handled just as many cases against MetLife throughout the country.

Contact us for a free consultation to discuss a claim with MetLife or any other disability insurance company. There are usually steps that can be taken to extend benefits beyond the 24 month limitation.

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