In the recent case, Charneski v. Metro.Life 2013 U.S.Dist.Lexis 176855, an Alabama judge determine that MetLife’s decision to terminate the LTD benefits of a service employee of a car dealer who suffered a back injury requiring surgery, was de novo wrong. Charneski‘s doctors all state that he is disabled from performing any gainful occupation due to pain in his back as well as radiculopathy (nerve damage causing pain shoot down the leg). He was approved for Social Security benefits as well. However, MetLife’s plan had a provision stating that it will only pay LTD benefits for 24 months for conditions that are self-reported including any neuromuskuloskeletal and soft tissue disorders. MetLife retained a physician to perform a paper review of Charneski‘s records who determined that there were no exceptions to the 24 month self-reported illness limitation, leading to MetLife’s termination of benefits.
A Treating Physician Appropriately Diagnosed Radiculopathy Based on MRI Findings
Contained MetLife’s 24 month Self-Reported Pain Limitation are several exclusions, one being radiculopathy. If a claimant can show that he or she has been diagnosed with radiculopathy through objective testing, then he or she can be paid beyond 24 months for a musculoskeletal condition. In this case, MetLife argued that an MRI was not sufficient to diagnose radiculopathy, that an EMG was necessary but was never performed. The Judge reviewed all the medical records and test results and determined that an MRI is absolutely appropriate to diagnose radiculopathy and that an EMG or other testing was not necessary. Furthermore, the plan did not state that an MRI was not considered objective evidence for the diagnosis of radiculopathy. Even though MetLife’s physician stated that other tests can be done to diagnose radiculopathy, there was no evidence presented that an MRI in itself was not objective medical evidence that could be used to support a diagnosis of radiculopathy.
If you have a MetLife plan that contains a similar 24 month limitation, be sure to inform your doctors that in order for you to remain on disability you must provide your insurance company with testing indicating objective proof of one or more of the exceptions spelled out in your plan.