MetLife determined a disability claimant with Fibromyalgia was not disabled after two years of receiving benefits, but a California Federal Judge disagreed. Federal courts in California have stood behind employees and forced insurance companies to pay disability benefits. We want to be your California disability attorney and make the disability insurance company pay your benefits. The law governing disability insurance claims is complex and often skewed in favor of the insurance company. Let’s take a look at a court decision in which a California Federal Judge reversed a MetLife disability denial.
MetLife is Ordered to Pay Disability Insurance Benefit
In Lavino v. Metropolitan Life Insurance Company, a federal court in California found that the insurer had abused its discretion in denying long-term disability benefits under an ERISA plan. The plaintiff had been a civil project engineer for ten years. However, she sought medical leave and disability benefits in 2005 due to chronic pain and fatigue linked to fibromyalgia. After paying benefits for nearly two years, the definition of disability changed from own occupation to any occupation. The claimant was forced to return to work – even though her condition had not improved and her doctor still considered her unable to perform any work.
MetLife Denial of Long Term Disability Benefits Includes Numerous Mistakes
When the plaintiff sued to recover the disability benefits, she pointed to procedural and substantive mistakes in the way MetLife processed the claim, including:
- MetLife misclassified the plaintiff’s job position as light duty when, by MetLife’s own prior analysis, the position was medium duty;
- MetLife failed to provide its paper medical reviewer – upon whose opinion was the sole basis for the denial of benefits – with important details about the claim;
- MetLife imposed a requirement of objective evidence to show a disability when the plan had no such requirement; and
- MetLife reversed its position after two years of accepting the plaintiff’s medical record as indicative of her inability to work.
The California federal court found that MetLife had abused its discretion in denying the benefits. The court recognized that, although the plan gave MetLife discretion, that discretion has limits. Sometimes a searching inquiry is required and this was one of those instances. MetLife decided who got benefits and Metlife was also responsible for paying those benefits. This necessarily created what the court described as a structural conflict of interest. With a financial incentive to deny coverage, the court refused to overlook the unreasonable and arbitrary manner in which MetLife denied benefits. These actions cast doubt on MetLife’s ultimate conclusion. The court’s skepticism led it to find that MetLife’s denial of long-term disability benefits could not be sustained and ordered MetLife to reinstate benefits.
Lavino v. Metropolitan Life Ins. Co., 779 F. Supp.2d 1095 (C.D. Cal. 2011).