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Dell & Schaefer ERISA Administrative Appeal Proves to MetLife that Client is Still Disabled and Claim Not Subject to Certain Policy Limitations

Attorney Alex PalamaraAuthor: Attorney Alex Palamara

Dell & Schaefer is happy to report that a client of ours is back on claim and receiving Long Term Disability (LTD) Benefits once again from the Metropolitan Life Insurance Company. Our client contacted us after receiving a denial letter from MetLife dated June 26, 2014. Prior to this time, she had received LTD benefits with no issue for almost two years. Unfortunately for our client, MetLife incorrectly determined that our client’s main disabling condition was fibromyalgia. The Long Term Disability Policy governing our client’s claim is a policy she was covered under due to her employment at The ServiceMaster Company. This particular policy limited benefits to 24 months for certain disabling conditions which include “mental or nervous disorders” or “for disabilities due to neuromuscular, musculoskeletal or soft tissue disorder and chronic fatigue syndrome and related conditions.” After receiving MetLife’s June 26, 2014 denial letter, our client found us and quickly became a client of Dell & Schaefer.

MetLife’s Denial Letter

In its denial letter of June 26, 2014, MetLife stated that our client’s “current disabling diagnosis of fibromyalgia falls under the limited benefit provision” of the Plan and benefits are limited to 24 months to the date of July 15, 2014. MetLife’s denial letter also stated that its medical director “took into consideration (her) diagnoses of lupus, diabetes, diabetic neuropathy, shoulder pain, osteoarthritis and coronary artery disease and determined that the medical information did not support that (she) would be prevented from performing the duties of (her) sedentary occupation for these diagnoses.”

Administrative Appeal filed by Dell & Schaefer

As The ServiceMaster Company LTD Policy is governed by the Employee Retirement Income Security Act of 1974 (ERISA), 180 days was given for our client to file an administrative appeal. With the help of Disability Attorney Alexander Palamara of Dell & Schaefer, a timely appeal was filed. The appeal noted that MetLife’s denial was primarily based on an internal review by one of its own employees. As such, MetLife did not have any independent physicians examine our client nor did any independent physicians conduct a review of our client’s medical records. Instead MetLife merely relied upon a biased review of one of its own employees. Furthermore, the appeal focused on the tremendous amount of support by our client’s treating physicians who supported our client’s claim as well as the extensive objective documentation that proved that our client’s conditions beyond fibromyalgia were enough to satisfy the definition of disability in the policy.

Re-Approval for Long Term Disability Benefits

Within 90 days of the filing of the administrative appeal, our client was informed that MetLife had overturned its previous decision to deny our client’s continued claim for benefits. MetLife has found that our client is “unable to earn more than 80% of her predisability earnings at any gainful occupation for any employer in her local economy for which she is reasonably qualified taking into account her training, education and experience.”
Our client is aware that the fight will continue as MetLife can attempt to deny her claim at any point in the future. However, our client can rest assured that the Attorneys at Dell & Schaefer will continue to fight MetLife so that she continues to receive her monthly LTD benefits so that treatment can continue.

If you have been denied Long Term Disability Benefits by MetLife or any other insurance provider, please do not hesitate to contact the Attorneys at Dell & Schafer for a free consultation.

Read more about fibromyalgia and disability claims.



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