Application for Long-term Disability Under Kaiser Health Plan
Renee Monroe worked as a Human Resources Compliance Specialist for Kaiser Foundation Health Plan, Inc. (“Kaiser”). Beginning in 2013 Ms. Monroe began experiencing significant low back pain and was taking off of work by her physicians. An MRI of her lower back indicated diffuse disk bulges at the L5-S1 vertebral disc. Ms. Monroe applied for long-term disability benefits through the Kaiser’s group long-term disability insurance with MetLife.
The Kaiser Long-term Disability Plan defined disability or disabled as: “that as a result of Sickness or injury You are either Totally Disabled or Partially Disabled.” The Plan defined Totally Disabled or Total Disability: “[d]uring the Elimination Period and the next 24 months, You are unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue Your Usual Occupation in the usual and customary way.” After 24 months, the definition of disability changes are requires the claimant to be unable “to engage with reasonable continuity in any occupation in which the claimant could reasonably be expected to perform satisfactorily in light of the claimant’s age, education, training experience, station in life, and physical and mental capacity.”
In addition, in order to begin receiving benefits under the long-term disability plan the claimant must meet the definition of total disability for 180 days, which is called the elimination period. After remaining totally disabled for 180 days only then will the claimant begin receiving benefits.
MetLife Denial of Long-term Disability Benefits and Appeal
Following submission of her long-term disability claim, Monroe received a letter from MetLife informing her that her long-term disability claim was being denied. MetLife claimed that it reviewed her medical records and determined that the records were insufficient in showing significant diagnostic test result and treatment to conclude that she was unable to perform her usual occupation of HR Compliance Specialist.
Monroe appealed MetLife’s denial of her long-term disability claim challenging its finding and the opinions of its medical reviewers.
During the course of the appeal review MetLife referred Ms. Monroe’s file for a paper review by its physician consultant board certified in Internal and Physical Medicine, Dr. Mark Hinrichs. Dr. Hinrichs reviewed the medical records and produced his finding to MetLife through a report. At no time did Dr. Hinrichs speak with Ms. Monroe or any of her treating physicans.
Dr. Hinrich’s report claimed that although the medical record was supportive of physical impairment for chronic low back pain and lumbar strain/sprain with lumbar spondylosis and plantar fasciitis that Monroe could lift up to 10 pounds occasionally, sit without restrictions and stand for up to 30 minutes with a five-minute break to sit, among other things….
MetLife then arranged to have a vocational rehabilitation consultant review the file who identified Ms. Monroe’s major duties as data entry and tracking of information and that her job required her to sit for up to seven to eight hours per day and that standing was not an essential function of her job. The vocational rehabilitation consultant found that the restrictions and limitations determined by Dr. Hinrich “would leave her able to undergo her usual, customary duties, as her job is primarily sitting and is documented to be sitting 98 percent of the day.”
Based on the report from Dr. Hinrich and its vocational rehabilitation consultant, MetLife upheld its decision to deny Ms. Monroe’s long-term disability claim. In summary, MetLife claimed that although Ms. Monroe had some restrictions and limitations that those restrictions and limitations would not preclude her from sedentary work.
California Federal Court Finds That MetLife Wrongfully Denied the Long-term Disability Claim
Following MetLife’s appeal denial, Monroe filed suit in the United States District Court for the Eastern District of California seeking recovery of her long-term disability benefits under ERISA.
The Court was to decide whether Ms. Monroe met her burden of showing, by a preponderance of the evidence, that she was disabled from her usual occupation during the period from when she stopped working through the time that it was to enter its judgment. MetLife of course argued that Ms. Monroe could not prove that she had functional impairments that rose to the level of a disability under the terms of the Kaiser Long-term Disability Plan.
Following its review of the administrative record and the legal briefs filed by Ms. Monroe and MetLife, the court concluded that Ms. Monroe was totally disabled from her usual occupation as an HR Compliance Specialist. Notably it found that Ms. Monroe’s medical records and the opinions of her treating doctors corroborated her claim that she was unable to sit or stand for a sufficient amount of time to perform the duties of her sedentary occupation. It also found MetLife’s failure to order an examination of Ms. Monroe during its initial claim review or appeal to be suspiciously, especially since it conceded that Ms. Monroe in fact had medical conditions. “A single in-person examination would have gone a long way in allowing MetLife to assess Plaintiff’s credibility and level of pain.”
Although this case was not handled by Attorneys Dell & Schaefer we believe that it is beneficial to those struggling to recover long-term disability benefits. If you need assistance with a similar matter please contact Attorneys Dell & Schaefer and ask to speak with our disability attorneys.
Read more about Metlife disability insurance claims.