Metlife Admits Decision to Deny LTD Benefits Based on Fibromyalgia Limitation Was Incorrect When Claimant’s Primary Diagnosis Was Meniere’s Disease
Author: Attorney Rachel Alters
Many MetLife LTD policies contain a provision limiting benefits to 24 months for several conditions including mental nervous conditions and fibromyalgia. It is important to be aware of this when filing a claim with MetLife as if you get approved under one of these conditions, you will only be allowed to collect benefits for 24 months. If your disabling condition falls outside of this limitation, but you also have fibromyalgia or a mental nervous condition that is not your primary disabling condition, it is pertinent that your treating physician list that condition as your primary disabling condition or you will only be permitted to receive 24 months of benefits.
MetLife Focuses Solely on Fibromyalgia, when True Disabling Condition is Meniere’s
In a case handled by attorney Rachel Alters, MetLife terminated her client’s benefits claiming that she had already been paid 24 months for fibromyalgia. In its denial letter, MetLife agreed that the claimant had been diagnosed with Meniere’s Disease, Vertigo, Sensorineural Hearing Loss, Tinnitus, Imbalance and Poor Concentration, all of which are not limited conditions under the policy. But MetLife claimed that none of these conditions were disabling. MetLife ignored the claimant’s treating physicians’ opinions that she was unable to work in any gainful occupation as a result of her restrictions and limitations due Meniere’s Disease. MetLife conveniently ignored the documentation in her medical records and opinions of her physicians and relied on the paper reviews of its hired consultants who had never met or examined the claimant. MetLife conceded in the denial letter that she was disabled due to a neuro musculoskeletal disorder, fatigue and fibromyalgia as those conditions are limited to 24 months of benefits which she has already been paid for. This was an incorrect interpretation of the claimant’s restrictions and limitations as she was clearly disabled as a result of Meniere’s Disease, Vertigo, Sensorineural Hearing Loss, Tinnitus, Imbalance and Poor Concentration, all conditions that are not limited to 24 months.
In fact, the Social Security Administration determined that the claimant had been disabled since December 8, 2009 as a result of Meniere’s vestibular disorder, loss of hearing on the left, carpal tunnel and osteoarthritis. MetLife also chose to ignore the determination made by the SSA. After receiving a detailed appeal by Dell & Schaefer which included opinions from the claimant’s treating physicians who were adamant that her primary disabling condition was not fibromyalgia, but Meniere’s Disease, MetLife sent her records two physicians to conduct a paper review. One of the reviewing physicians agreed that she suffered from the effects of Meniere’s Disease and could not work in a full-time sedentary capacity. MetLife reversed its decision to deny her benefits, paid her past benefits owed and reinstated her monthly benefits.