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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