Court Finds MetLife Has No Right To Request An IME After Unnecessary Delay

Recently, a claimant was forced to hire a California Disability Lawyer and file a lawsuit against MetLife after being denied continued Long Term Disability Benefits. After agreeing with the claimant that she was disabled through the “own occupation” period, the Court awarded the claimant benefits for that limited time period. However, the court then asked MetLife to take a closer look at the “any occupation” period. For an unexplained reason, MetLife dragged its feet on making a determination.

The question in Kroll v. Kaiser Foundation Health Plan Long Term Disability Plan et. al. and the insurer’s Motion to Compel an Independent Medical Exam (IME) concerned whether or not the insurer waited too late to request a IME for the claimant after the Court had remanded the original complaint concerning an abuse of discretion when the insurer incorrectly awarded Kroll disability benefits during the “own occupation” period.

The Court, in its original ruling, remanded Kroll’s claim back to MetLife so the decision could be to re-reviewed during the “any occupation” period. The remand occurred on May 13, 2011; and, MetLife requested that Kroll appear for an IME in October 2011. According to 29 C.F.R.§ 2560-1(f)(3), the insurer was to either settle Kroll’s claim within 45 days or inform her that they needed more time and information to make a decision. The insurer did neither. Kroll however did provide MetLife with some 1,000 pages of medical records to supplement her claim, which should have triggered some response from the insurer. Unfortunately, for the insurer, it waited too long to request an IME, and thus, the District Court Judge ruled that the insurer did indeed fail to make its request in a timely fashion, and thus, Kroll was not required to provide it with an IME.

45-Day Rule Wins Case for Claimant

Consequently, in its order denying the Motion to Compel, the Court pointed out that the purpose of the 45-day rule per the Employee Retirement Insurance Security Act of 1974 (ERISA) is to see that claimants are able “to resolve disputes over benefits inexpensively and expeditiously.”

And, since MetLife was unable to offer any reasonable explanation as to why it delayed in either notifying Kroll that it wanted an IME, providing her with forms to file her claim under the “any occupation” standard, the Court felt it had no alternative but to deny MetLife’s Motion to Compel, stating that it is too late for the insurer to request an IME and that for all intents and purposes “the Plaintiff’s claim for long term disability benefits under the ‘any occupation’ standard is deemed exhausted.”

For similar cases and more information on MetLife, please click here.

Comments (10)

  • Sandra,

    You are definitely entitled to hire your own SSDI attorney. Any fee received by the attorney will be received from the SSDI benefit you receive. The attorney fee amount will NOT be recoverable by the insurance company under the offset provisions of the policy.

    Stephen Jessup Aug 15, 2013  #10

  • Sandra,

    Some carriers will not consider lump sum buyouts of group disability policies. The ones that do usually require SSDI to be approved prior to considering a lump sum buyout. Unfortunately, an insurance company can deny your claim at any time based upon what it believes to be reasonable grounds, this includes prior to receiving SSDI benefits and even after receiving benefits. Disability insurance benefits are never guaranteed and entitlement to same is a month to month review by the insurance company.

    Stephen Jessup Aug 15, 2013  #9

  • I want to get an attorney for my SSDI and not use the attorneys in the social security department affiliated with the long term disability insurance company. What do I need from the insurance company to be able to retain and pay attorney’s fee instead of the insurance company getting the offset money when claim is approved? I cannot afford to pay an attorney 25% out of pocket. Attorneys refuse to take my case when they know an offset document was signed over to the insurance company.

    Sandra Aug 14, 2013  #8

  • How do I go about getting my long term disability insurance company to give a lump sum payout and should I wait until after I receive SSDI approval to make the request? Can the insurance company deny long term benefits before an appeal has been done when denied by the Soc. Sec. Admin.?

    Sandra Aug 14, 2013  #7

  • Robin,

    I would recommend either trying to contact the agent who sold you the policy, which may be difficult, or in the alternative request from MetLife copies of any changes to your policy over the years. If you exercised any increases in coverage, it may have affected the language of your policy. Additionally, you can simply ask MetLife to explain why what you have is different from what you have.

    Stephen Jessup Jun 10, 2013  #6

  • Mr. Dell, thank you for your response to my question, however, my disability policy is an individual and not group policy. The issue date on the copy sent to me my MetLife is the same as on the policy I was originally issued. I am not sure if this information would change your response.

    Robin Jun 9, 2013  #5

  • Sherri,

    This is a typical technique used by MetLife and you will need to file an appeal of the denial. These are the type of MetLife disability denials that we handle on a daily basis. The limitation you have mentioned above is very restrictive, but you may have a case that can be won.

    Gregory Dell May 31, 2013  #4

  • I had work injury and I am still under doctor’s care for my worker’s comp. case. I have long term disability with MetLife.

    Under the company plan they accept the claim more than 24 months if the problem is falling to their category.

    I have a back pain and in my last MRI Report I have Hemangioma at L2 vertebral body.

    According their policy:

    If the disability has objective evidence of:
    *spinal tumors, malignancy or vascular malformations
    There is no limit for disability benefits.

    When I faxed the last MRI report, my case manager said: unfortunately it is in your MRI but your doctor did not mentioned in his report that the Hemangioma is your primary disability condition. We need this evidence in your doctor’s report.

    So I asked my doctor and I got the report that Hemangioma is my primary disability condition. And after 1 week they called me and I was told it doesn’t pressure and damage the nerve root and they didn’t say there is a pressure because of that… What the in the world…

    They try to close my case by June 7th.

    Sherri May 30, 2013  #3

  • Robin,

    Sometimes group disability policies can be reissued before the date you become disabled, so you need to verify the issue date of the policy that was sent to you. The ERISA group policies can change.

    Gregory Dell Apr 13, 2013  #2

  • In February 2013, I filed a disability claim for chronic back problems dating back to December 2012, with MetLife as the administrator of a policy I have with Lincoln National. I also requested a copy of my policy because I couldn’t find my issued policy from Lincoln. To date, I’m still waiting for approval of my disability claim [policy period 12 months, indemnity $500 issued july 1978]. In the meantime, I just found my original issued policy and it differs from the copy I was sent and there are two pages with my signature that isn’t my signature. I’m not sure what to do. Any advice would be appreciated. Thank you.

    Robin Manor Apr 11, 2013  #1

Leave a comment or ask us a question

Questions About Hiring Us

Do you help MetLife claimants nationwide?

We represent MetLife clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a MetLife disability insurance policy?

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.

How do you help MetLife claimants?

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
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

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.

What are your fees?

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.

Do I have to come to your office to work with your law firm?

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, GoToMeeting.com 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.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Ravindra P.

I have been a client of Dell & Schaefer for the 6 months and they have already successfully taken my disability claim to approval. It is privilege to write this testimonial. I am a professional myself, a physician and to me these are some of the core strengths of Steve Jessup and his team.

Listening to the client: Attorneys at Dell & Schaefer really listen to you explain your special situation and undoubtedly every one of us has a special circumstance and specific wishes as to what we want. Most of the time attorneys and in general most professionals these days, will listen to you a couple of minutes and then file you away in a category or a bin and chalk out a plan for you in their mind and stop listening to you and start thinking about the next thing that they have to do. That is why these interactions are so often exasperating for the client.

As a physician I used to try and teach medical students that any well trained monkey can read a few books and do a particular thing in a particular situation, it is however extremely essential that you determine what the situation is and no one understands the situation better than your client or patient. I spoke to a couple of attorneys at D&S, initially with someone who took my call and then Steve who was assigned to me and it was impressive that they really tried to get what I was trying to convey, what my special and unique situation was (and whose isn’t?) and what I wanted.

Shock and Awe: At Dell & Schaefer they don’t go in halfway prepared. Their philosophy is to get well prepared and go in guns blazing. They will make you work on your mission until all anticipated difficulties have a contingency plan before even the adversary is intimated of the challenge. I believe it was Sun Tzu who said that the best battles are won before they are fought. Frequently you are a small David pitted against a Goliath adversary with deep pockets and a much larger time horizon. But you do have an advantage, that of time for preparation. The adversary does not know of the battle until you tell them and then the clock starts ticking. At Dell & Schaefer they make full use of your advantage by preparing your case with utmost thoroughness before the engagement.

Art of the possible: Legal action, just like life, is the art of the possible. I have dealt with 5 other attorneys in my career and only one of them apart from Dell & Schaefer understood this. A professional’s job is to tell you what the score is, what possibly can occur in the future and what measures can be taken to favorably change the future. And the last one is possibly the most vital. You don’t want your attorneys telling you all the time why things cannot be done, how laws are stacked against you, how global warming is melting the icecaps, how the oil is running out and how dogs sometimes eat homework assignments. You want them taxing their brains to see what can be done in best manner possible, so the future, which is not yet written, changes favorably for you. Attorneys at D&S get this and consciously incorporate it in their work ethic.

They say that there are four professionals in your life who should also be your friends. Doctor, Lawyer, Accountant and Banker. There is a deeper side to this sound bite that some people get and some don’t. I live at the other end of the country from where Dell & Schaefer work and play, but the world is small and getting smaller and perhaps someday I can add to my stock of friends.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us