Florida Courts Have A Complicated Six Step Disability Insurance Denial Protocol

When a reviewing court considers an appeal of a disability benefit denial, it is rarely a simple question. The court has the responsibility to examine the policy, the claimant’s condition and the insurance company’s actions in handling the disability benefit claim. And because the insurance company has the right to make certain decisions about the policy, the court is often required to give the insurance company the benefit of the doubt. The case of Blankenship v. Metropolitan Life Insurance Company illustrates this point.

MetLife Denial Of Disabilty Benefits is Upheld by Florida Appellate Court

The claimant suffered a heart attack in August 2003 and received short-term disability benefits followed by long-term benefits. But MetLife terminated all disability benefits on December 31, 2004. The claimant appealed MetLife’s decision to terminate his benefits and submitted letters from his doctors stating he could not return to work due to stress. In February 2005, the claimant underwent surgery for a knee injury and MetLife reinstated his long-term disability benefits through May 2005. MetLife then informed the claimant his eligibility for long-term disability benefits would end in January 2006 unless he could show he was eligible under the plan’s “any occupation” defintiion of disability.

During its review of the claimant’s case, MetLife considered a report from an independent medical consultant hired by MetLife. The consultant concluded that the claimant could perform desk (or sedentary) work so MetLife determined that the claimant did not qualify for benefits under the Plan’s “any occupation” disability definition, informing him his benefits would end in January 2006. The claimant appealed and, after MetLife had the claimant’s file reviewed by three medical specialists, it denied the appeal. The claimant then sued after having exhausted his ERISA appeals. The claimant asserted that MetLife – as the administrator making claim decisions and as the payor of those claims – had a conflict of interest that tainted the disability benefit claim denial.

Florida Has a Six-Step Process to Review Disability Benefit Denials

The Eleventh Circuit Court of Appeals – Florida’s highest federal court – held that MetLife had not violated the law. The court first explained the applicable six – step standard for reviewing a disability insurance denials governed by ERISA, which included:

  1. Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is “wrong” (i.e., the court disagrees with the administrator’s decision); if it is not, then end the inquiry and affirm the decision.
  2. If the administrator’s decision is de novo wrong, then determine whether he was vested with discretion in reviewing claims; if not, end judicial inquiry and reverse the decision.
  3. If the administrator’s decision is “de novo wrong” and he was vested with discretion in reviewing claims, then determine whether “reasonable” grounds supported the decision (hence, review his decision under the more deferential arbitrary and capricious standard).
  4. If no reasonable grounds exist, then end the inquiry and reverse the administrator’s decision; if reasonable grounds exist, then determine if he operated under a conflict of interest.
  5. If there is no conflict of interest, then end the inquiry and affirm the decision.
  6. If there is a conflict of interest, then apply heightened arbitrary and capricious review to the decision to affirm or deny it.

In analyzing this six-step standard, the court reiterated that “the burden remains on the plaintiff to show the decision was arbitrary; it is not the defendant’s burden to prove its decision was not tainted by self-interest.” While the court must account for a conflict of interest, when one exists, as a factor in the analysis; the basic analysis still focuses on assessing whether a reasonable basis existed for the administrator’s benefit decision. After reviewing the record, the court concluded that MetLife had a reasonable basis for its benefit denial and its conflict of interest did not render those decisions arbitrary or capricious. The denial was upheld.

Blankenship v. Metropolitan Life Ins. Co., 644 F.3d 1350 (11th Cir. 2011)

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