Our client, a former Executive Assistant at American Express, filed a claim with MetLife under American Express’s short term disability policy on account of severe cervical and thoracic pain with resulting radiculopathy that made it impossible for her to execute her job duties. Based on the medical information provided, MetLife quickly approved our client’s for claim for short term disability with little resistance. However, as the short term disability period began to reach its end our client began to experience a different side of MetLife.
The transition to Long Term Disability
Like the vast majority of short term disability policies, our client’s policy was funded by her employer, but was administered by MetLife – meaning the actual payment of short term disability benefits was paid by American Express and MetLife’s only responsibility was to advise American Express if the claim was approved or denied. As such, MetLife was not financially vested in her short term disability claim. However, as the long term disability policy was underwritten by MetLife, MetLife would be responsible for paying any resulting long term disability benefits. When it became evident that our client would not be able to return to work and that she would need to file for long term disability benefits, MetLife’s attitude towards her changed.
All of a sudden medical information provided was “not received” or when it was, it was deemed unsupportive of disability. Essentially, the same information MetLife used to approve short term disability benefits was now being used in an attempt to deny her long term disability benefits. Our client remained hopeful that MetLife would do the right thing and pay her benefits, but with each passing week without pay her financial hardship only worsened. After feeling defeated and getting nowhere with MetLife she contacted our office and spoke with Attorney Stephen Jessup. After discussing all that had transpired with Attorney Jessup she retained his services to takeover handling the claim with MetLife.
Attorney Jessup immediately contacted MetLife to advise the claims manager of our representation and set to work on gathering the information needed to ensure our client’s claim would be approved. Based on his experience in dealing with MetLife disability claims, Attorney Jessup knew that MetLife was making two arguments with which to try to deny our client’s claim:
- As our client had been working with her medical condition for some time MetLife was questioning why she needed to file for disability now. Essentially, MetLife was asking, “What changed?”
- A lack of objective medical evidence to support restrictions and limitations. This is a very common position to take when the basis of disability is pain related. MetLife will argue that the complaints are all subjective and not verifiable. This is the commonly used “Diagnosis does not equal disability” argument from MetLife.
Attorney Jessup has dealt with these issues numerous times and knew it would be important for our client to get an updated MRI to document “what changed” and to undergo a Functional Capacity Examination in order to verify that our client’s “diagnosis did equal disability.” The updated MRI indicated that our client’s condition had in fact worsened since the prior MRI performed two years earlier. Attorney Jessup knew this would greatly assisted in responding to MetLife’s “what changed” argument. All that was left was to have the Functional Capacity Examination performed.
Medical File Review
As Attorney Jessup was working with our client and her doctors to gather the necessary medical information MetLife forwarded a copy of a medical file review performed by one of its doctors and requested that our client’s doctor respond to the findings therein. Any time an insurance company sends a medical review and requests a response it is clear that their intention is to deny the claim. In the letter MetLife gave a limited timeframe with which to respond, the deadline of which came two days before our client was scheduled to undergo her FCE.
MetLife’s medical review contained a glaring problem – when rendering his opinion, the doctor did not have all of the applicable medical documentation – specifically he did not have the updated MRI. On March 6 our office provided MetLife with the updated MRI findings. However, the medical review was completed on March 4 and the doctor relied on the earlier MRI from two years prior. This MRI information ultimately led MetLife’s doctor to render an opinion that our client would be physically able to perform her work duties. This would have been an excusable mistake but for the fact that despite having the updated MRI on March 6, MetLife didn’t provide it to the doctor and request he consider it and issue any addendum to his report on account of same. Instead, MetLife sent the doctor’s report to our office on March 11 for review and comment.
The day after we received MetLife’s doctor’s report the COVID-19 pandemic swept the country, and our client – a resident of New York City found herself in a citywide lockdown. Needless to say the FCE would not occur for the foreseeable future. Despite this extraordinary situation MetLife denied all extensions to provide information. Attorney Jessup responded in full as to MetLife’s failure to provide crucial medical information to its doctor, and without the ability to have the FCE testing performed, worked with our client’s doctor to provide a response to MetLife’s medical review.
After nearly another week without pay and filled with uncertainty and fear as our client was isolated in her apartment as the coronavirus brought New York City to a standstill, MetLife notified our office that it was approving our client’s claim for benefits. Had MetLife provided the updated MRI to its doctor when they received in on March 6 there stands a good chance that our client’s claim would have been approved weeks earlier.
Our client believes had she tried to deal with MetLife on her own they would not have approved her claim. Her claim serves as an unfortunate example of how MetLife will try to look to deny a claim for long term disability as it transitions from a period of short term disability.
If you are having issues with MetLife paying your claim or have any questions regarding a MetLife disability issue, please do not hesitate to contact our office to speak with one of our disability attorneys.