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.”

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There are 10 comments

  • 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 JessupAug 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 JessupAug 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.

    SandraAug 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.?

    SandraAug 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 JessupJun 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.

    RobinJun 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 DellMay 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.

    SherriMay 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 DellApr 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 ManorApr 11, 2013  #1