In Tash v. Metropolitan Life Insurance Company (MetLife), Raymond Tash, a dentist, became disabled due to multiple injuries and was initially granted disability benefits when he could no longer work in his own occupation. After one year, MetLife discontinued its payment even though the policy provided for 24 months of benefits, so the dentist filed an ERISA lawsuit. That lawsuit was settled. MetLife paid Tash a sum of money and agreed to evaluate whether or not he qualified for benefits under the “any occupation” standard.
The “any occupation” definition required the plaintiff to be disabled if he was “unable to earn 60% of his prior earnings in ‘any gainful occupation’ that he is qualified to do.” This period began on February 11, 2013. Plaintiff’s documents supporting his claim were submitted in a timely fashion, which required MetLife to decide the claim by September 22, 2014. Despite the plaintiff’s repeated letters requesting MetLife to decide one way or the other, no decision was made. On December 3, 2014, almost three months after there should have been a decision, the plaintiff filed this ERISA lawsuit. MetLife only issued a denial letter on February 24, 2016, which was two days before the court ordered trial briefings to be filed. “As such,” the court commented, “Dr. Tash was denied his ability to submit evidence challenging MetLife’s grounds for denial before starting the litigation.”
The California Judge Reprimands MetLife for its Failure
The California judge deciding this case expressed his displeasure with MetLife by severely reprimanding it for its violation of ERISA statutory and regulatory procedures which “create an administrative procedure in which the claimant has the opportunity to introduce relevant evidence into the record.” If claimants are not given specific reasons for the denial, they cannot prepare an administrative appeal or properly prepare their case for a decision by a federal court. Although MetLife requested to file more documents with the court to justify its late denial, the court held the administrative record was closed on September 22, 2014, the date upon which MetLife should have either approved the claim or issued a denial letter.
The court found that “Met Life’s procedural defaults significantly disrupted the process of litigation in this Court. MetLife’s unexplained refusal to issue a denial letter until the eve of trial turned this case from a straightforward issue of whether Dr. Tash was disabled under the Plan into a tangled accumulation of filings and counter-filings regarding matters that distract the Court from the merits of this case.”
The court issued orders based on MetLife’s “violation of ERISA and the resulting prejudice to Dr. Tash” and ordered it to:
· Pay back benefits with interest to Dr. Tash beginning on February 11, 2013 until the date of the order.
· Continue to pay benefits “unless and until it issues a denial that fully complies with ERISA.”
The case was remanded to MetLife “for a determination that complies with ERISA of Dr. Tash’s benefits under the ‘any occupation’ provision of the Plan.”
This case was not handled by our office, but it may provide claimants guidance in their pursuit of long term disability benefits when their insurer refuses to take action on their claim. If you need assistance with a similar matter, or any other issue relevant to your disability claim, please contact any of our lawyers for a free consultation.