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)

Comments (2)

  • Nora, yes, we do handle short term disability appeals, however, most times it must be connected to a long term disability claim. There are a few instances where we can help people if it is only a short term disability claim. Please contact us so that we can learn more about your claim for benefits.

    Alex Palamara Sep 13, 2022  #2

  • Do you handle short term disability appeals for ERISA plans?

    Nora Sep 12, 2022  #1

Leave a comment or ask us a question

Questions About Hiring Us

Do you help MetLife claimants nationwide?

We represent MetLife clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a MetLife disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from MetLife. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by MetLife.

How do you help MetLife claimants?

Our lawyers help individuals that have either purchased a MetLife long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with MetLife:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Jacqueline R.

Best attorney in the industry! I have worked with Greg Dell for the past 10 years. He and his team have been excellent in every way! I was forced to retire early from dentistry due to arthritis in my hands. I had no idea how manipulative the disability carrier could be, and ultimately decided to have Greg help me with my claim.

He has been diligent in protecting my rights and responds to me immediately when I have a question or concern. I highly recommend him and his company – 5 stars for professionalism, response time, knowledge and commitment to their clients.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us