Prior to contacting our office, our client filed a claim for long term disability benefits under his individual disability insurance policy with MetLife on account of de Quervain’s Tenosynovitis, a condition affecting the tendons of the thumb and wrist that resulted in severe pain in his dominant hand, especially with grasping. Given the nature of his occupation as a Dentist, and the fact his condition was affecting his dominant hand it was clear that he would pose a risk to patients should he continue to practice dentistry. Accordingly, MetLife initially approved our client’s claim. While on disability he underwent surgery to alleviate the symptoms but the results of surgery were less than ideal.
Continued Claim Review
Despite undergoing the surgery our client continued to experience throbbing pain in his wrist and hand, which his surgeon could not determine the basis of in light of the surgery performed. With uncertainty as to the cause of pain, as well as what MetLife deemed to be the subject nature of same, in light of a “successful” surgery, MetLife began to question whether our client continued to meet the requirements of disability under his policy. In an effort to gain a better understanding of his continued symptoms our client sought a second opinion, which ultimately determined that our client was experiencing nerve damage, which was continuing to affect his ability to use his hand.
MetLife’s doctor’s review of the medical findings was not so clear and MetLife notified our client that it was denying his claim for continued benefits. Our client reacted immediately and availed himself of the voluntary appeal process MetLife offered under his individual disability policy. Shortly after filing the appeal, MetLife informed our client that it had arranged for him to undergo an Independent Medical Examination (IME) to better assess the extent of his medical conditions and ultimately determine whether MetLife would reinstate his claim for disability benefits.
Our client believed that the IME was positive/favorable to his claim and that the examining doctor agreed with his treating physician as to the nature of his continued complaints and there impact on his ability to perform the duties of a dentist. However, MetLife continued to drag its feet in finalizing its review and informed our client that it was seeking additional clarification from the IME doctor before it could render a decision. As nearly six months had passed since MetLife stopped paying benefits, and with no end in sight as to MetLife’s delay tactics, our client contacted our office to seek legal representation and spoke with Attorney Stephen Jessup.
The Claim Decision
Having represented numerous dentists over the past decade, Attorney Jessup was familiar with our client’s medical condition and how a private disability insurance carrier like MetLife would be evaluating the information to finalize a claim decision. Attorney Jessup’s first course of action was contacting MetLife to advise them that our client was now represented by counsel and to demand clarification as to the status of MetLife’s review of our client’s claim. A request was made that MetLife make payments to our client under Reservation of Rights while the review of his appeal took place, but MetLife was adamant that no benefits would be paid during the course of the appeal review.
Not willing to approve benefits without a fight and due to differing opinions of its doctors and our client’s, MetLife arranged for our client to undergo another IME with an occupational therapist specializing in examinations of the hand. Following this second examination, Attorney Jessup was able to secure a copy of the IME report from MetLife. Review of the IME report did in fact indicate that the examiner agreed with the findings our client’s doctor (and that of the initial IME doctor) of nerve pain that was resulting in not only continued pain of the right hand and wrist with use, but also numbness and loss of sensation throughout our client’s hand. Despite these findings MetLife did not approve our client’s claim immediately and advised Attorney Jessup that its medical reviewers were seeking clarification from the two IME examiners and our client’s doctor.
Attorney Jessup pressed our client’s position with MetLife and threatened to bring suit under the policy to secure our client’s benefits. In light of all the information in our client’s file, MetLife was left with little choice but to reinstate our client’s individual disability benefits and pay nearly a year in past due benefits. However, Attorney Jessup knows that the approval of the claim will not be the end of MetLife’s continued review and inquiries into the future of our client’s claim.
Is your disability carrier challenging your claim?
Our office has represented numerous dentists and other medical professionals in disputes with their disability carriers as they relate to medical conditions that limit the ability to perform occupational duties, but otherwise have very little negative impact on the client’s day to day activities. Insurance companies will challenge these claims when there is limited diagnostic evidence to support the claim, or as was the case with our client, standard diagnostic testing (EMG/Nerve Conduction Studies) did not clearly define a diagnosis. Rather, the diagnosis was made based on clinical examination.
It is imperative that an insured’s medical records accurately reflect the symptoms, restrictions and limitations that the insured is experiencing, especially in the absence of firm objective medical evidence.
If you have questions regarding your disability insurance policy/claim, please feel free to contact our office to speak with one of our disability insurance attorneys.