California Federal Court Orders Metropolitan Life Insurance Company to reinstate benefits to disabled analyst

Prior to disability, David Do was employed as an Analyst-Desktop services for IVZ, Inc. He was responsible to resolving and handling “all support calls relating to desktop software/hardware installation and maintenance.”

Mr. Do was insured under an employer sponsored long-term disability plan administered and funded by Metropolitan Life Insurance Company. In February 2013, Mr. Do injured his neck, back and shoulders while moving computer equipment, and as a result was forced to stop working and apply for workers compensation and short-term disability.

MRIs taken shortly after his injury showed degenerative disc disease and other abnormalities. Based on the objective and clinical findings, Mr. Do was diagnosed with lumbar disc disease and radiculopathy. MetLife approved Mr. Do’s long-term disability claim.

As the twenty-fourth month approached MetLife and its medical director, Dr. Joseph Monkofsky, reviewed the claim. Dr. Monkofsky reported that Mr. Do’s condition was consistent with right-side L5 radiculopathy, however, questioned whether Mr. Do suffered from significantly impairing effects which would prevent him from performing any gainful occupation. MetLife terminated benefits at twenty-four months claiming that the policy’s neuromusculoskeletal disorder limitation applied. The neuromusculoskeletal disorder limitation provided that “Neuromuscular, Musculoskeletal or Soft Tissue Disorder,” or a “disease or disorder of the spine or extremities and their surrounding soft tissue, including sprains and strains of joints and adjacent muscles,” had a maximum benefit duration of twenty-four months, unless he could show objective evidence of a number of exceptions, such as “Radiculopathies.”

Mr. Do appealed Metlife’s denial and submitted EMG and Nerve Conduction studies which confirmed that Mr. Do indeed suffered from bilateral lumbar radiculopathy. On appeal MetLife had Malcolm McPhee, a peer review physician, review the additional records and studies. Dr. McPhee quickly dismissed the EMG findings claiming that although “radiculopathy was considered” the clinical exam “revealed no focal findings in a nerve root pattern.” MetLife upheld its decision to deny benefits on appeal and Mr. Do filed suit in US District Court.

The Court examined whether Mr. Do had submitted sufficient evidence to establish that his conditions were the exception to the limitation, and found that not only was radiculopathy confirmed in Mr. Do, but that it was established by two EMG tests, MRI and clinical examination findings, contrary to Dr. McPhee’s findings. The Court also questioned Dr. McPhee’s credibility on account of his eagerness to so quickly dismiss the objective EMG findings when he had stated in a previous case that “[n]eedle electromyography [EMG] is the single most useful procedure diagnostically in cases of suspected radiculopathy.”

Judge Claudia Wilken ordered MetLife to calculate and pay all past benefits owed to Mr. Do and reinstate his claim.

Although this case was not specifically handled by Dell & Schaefer, the improper application of the neuromusculoskeletal limitation is an issue that we have dealt with many times and are very familiar with. If you have encountered a problem with MetLife or any disability insurer improperly applying a limitation provision to your disability claim, or claiming that your conditions which are exempt from limitation do not apply, please contact us.

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Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from MetLife. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by MetLife.

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Our lawyers help individuals that have either purchased a MetLife long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with MetLife:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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