MetLife denies long-term disability benefits to a consultant after approving them
In the case we are going to look at, a disability insurance attorney found himself representing a client who believed that Metropolitan Life Insurance Company (MetLife) had wrongfully denied the extension of his long-term disability benefits. This is a far too common occurrence, and one that disability insurance attorneys see frequently. As we look at this case, you will see that without the representation of a disability attorney, John Lanier would not have received his rightful benefits.
Lanier became a manager and software engineer when he left college. This led eventually to employment with KPMG Consulting, Inc. in 1999. In 2002, the company changed its name to Bearing Point, Inc. The change in name had no effect upon the employee benefits package, which included both short-term and long-term disability benefits administered by MetLife. The plan would consider Lanier disabled if during the first three years following an elimination period he was “unable to perform the material and substantial duties of (his) Own Occupation.” After the three years, the plan would only consider Lanier disabled if he couldn’t perform any job for which he was qualified for or could become qualified for when his training, education and experience were considered.
In his college days, Lanier had been an active man who did not drink or smoke. Despite his healthy lifestyle he began to experience back pain in his early twenties. The pain progressed to the point that it began interfering with his job duties which included extensive travel. This meant he spent considerable time walking, sitting, lifting and carrying a computer and luggage. If he wasn’t travelling by plane, he spent long hours driving a car. Lifting 10 – 20 lbs., carrying 10 lbs., and pushing or pulling 30 – 40 lbs. on a daily basis was a regular requirement of his position.
Beginning in 1999, Lanier resorted to surgery to see if it would alleviate his back conditions. He underwent a lumbar diskectomy and laminectomy in 1999, then a second laminectomy in 2001. Finally in October 2002, Lanier applied to MetLIfe for short-term disability benefits under his plan with Bearing Point.
His treating physician diagnosed him with chronic cervical and lumbar pain, left lumbosacral radiculopathy, congenital narrowing of the spinal canal in the lumbar region and fibromyalgia-like features expressed through chronic migratory pain, anatomical abnormalities with multiple impairments in the cervical and lumbar spine that were objective in nature, advanced degenerative arthritis in the lumbar spine at multiple levels, disc protrusion and spondylosis from C3 all the way through T2, bilateral ulnar neuropathy at the elbows and dysfunctional sleep-wake cycles.
Lanier was also diagnosed with depression and anxiety disorder during this time.
MetLife approves short-term disability. Disability insurance attorney not yet needed.
MetLife approved the short-term disability from October 9, 2002 through April 6, 2003. Lanier then applied for long-term disability benefits based on his severe fibromyalgia and osteoarthritis of the lumbar spine and degenerative disc disease. His application was approved on June 4, 2003, with an effective date of April 7, 2003. MetLife agreed to pay benefits for 36 months.
Six months before Lanier’s benefits were due for review at the higher standard of “any occupation,” he received notice that MetLife was not going to approve him for continuing long-term disability benefits. MetLife claimed that
- the office visit notes from his treating physician, Dr. Geoffrey Seidel, from April 25, 2005, July 26, 2005 and August 25, 2005;
- the prescription requests from June 11, 2005 and July 1, 2005;
- Dr. Seidel’s attending physician statement from August 25, 2005; and
- Dr. Seidel’s physical capacity evaluation dated August 25, 2005 demonstrated that he would be able to work in another occupation.
MetLife misreads physical capacity evaluation. Time to contact disability attorney arrives.
The primary document which MetLife relied on was Dr. Seidel’s physical capacity evaluation. This evaluation suggested that Lanier could sit for six hours and stand and walk for one hour. This suggested an improvement over a previous evaluation from January 9, 2003 that had said he could only sit for four hours intermittently, stand for one hour intermittently, and walk for one hour intermittently. The more recent evaluation suggested that Lanier would be able to work at a sedentary job such as chief bank examiner, controller with the Department of Transportation, or as a credit and collection manager.
Lanier appealed the decision in March 2006. It appears that he had hired a disability attorney by this time.
He included a new report from Dr. Seidel, dated December 5, 2005, which corrected misunderstandings conveyed in the August 25, 2005 physical capacity evaluation. He also provided proof that his application for Social Security disability benefits, as required by MetLife to continue his disability benefits, had received a favorable determination. He also included additional tests that confirmed his continuing disability.
- An electrodiagnostic test performed September 22, 2005 that confirmed his chronic left radiculopathy and proving that no changes have occurred since the 2003 test had been performed.
- Electrodiagnostic tests performed on his left and right elbows on September 28, 2005 revealing bilateral ulnar neuropathy.
- An MRI of the lumbroscal spine performed on September 23, 2005 confirming the congenital and chronic disc disease diagnosis and providing additional evidence of Dr. Seidel’s diagnosis of spinal nerve root compression.
- An MRI of the cervical spine performed on September 26, 2005 confirming the worsening condition of his multi-level degenerative disc disease and stenosis as compared to the 2003 MRI.
Doctor seeks to clear up misreading of physical capacity evaluation.
It must be noted that in his December 5 letter, Dr. Seidel explained why he was submitting a new evaluation that contradicted the one of August 25. He explained that he had mistakenly carried over a prior answer from the first page and that he wanted to emphasize that the answer had been incorrect and he wanted to clarify what the correct answer should have been. He noted that Lanier could only tolerate sitting for one to two hours per day working at a computer in a seated position. Whenever he tried to extend this length of time at the computer, he would get headaches and his back pain would become unbearable and the radicular symptoms also became unbearable.
Pointing to the ulnar neuropathy, Dr. Seidel said that it was unreasonable to expect Lanier to be able to perform typical sedentary work. He stated that the only way that Lanier could sit in one place was in a recliner in which he had head support, not a very practical work environment requirement.
Dr. Seidel also noted that Lanier had explored chiropractic care to see if it would help. The results had been inconsistent, and he had finally abandoned the treatments.
In addition to making his appeal on his actual physical condition, Lanier’s disability attorney also pointed to his mental health impairments. Documentation included a psychological evaluation from Dr. Patricia Pearson, who evaluated him for Social Security disability. She had diagnosed him with severe generalized anxiety, severe depressive disorder secondary to physical pain and limitations, and severe pain disorder with psychological factors associated with a general medical condition. She had concluded that he would be unable to do customary work.
Lanier also presented testimony presented during the Social Security proceedings. Vocational expert Elaine M. Tripi, PhD had reviewed Lanier’s symptomatology and limitations and functional limitations and reached the conclusion that he was “unable to perform his past or any other work that exists in the community.”
MetLife reverses decision to deny long-term disability benefits.
MetLife found this information compelling, and reversed its denial decision on June 14, 2006. The evidence of radiculopathy, exempted Lanier from a 24 month limitation that existed for neuromuscular and soft tissue disorders. They reinstated his long-term disability benefits effective as of April 7, 2006. It appeared that Lanier’s need for a disability insurance attorney had ended.
Because Social Security had awarded retroactive benefits to April 2003, MetLife claimed that it had overpaid Lanier by $60,440, less the cost of attorney fees for the time between April 7, 2003 through December 6, 2005. In order to recoup this loss, MetLife reduced Lanier’s monthly payments by the $1990 that Lanier received Social Security each month. MetLife also notified Lanier that it would withhold any further benefit payments beginning with January 2006 until it was able to recoup the entire remaining $55,148 in overpaid benefits. Lanier compensated MetLife for the overpayment on January 12, 2006.
MetLife reverses again. Denies long-term disability benefits a second time.
Then MetLife reversed itself again on February 6, 2007. The decision to terminate the plaintiff’s long-term disability benefits came, not because MetLife had new information about Lanier’s medical condition, but because it had sent his medical records that for review by new experts. One of the experts was a MetLife clinical specialist. The other was vocational rehabilitation consultant Mary L. Hale, who had reviewed Dr. Seidel’s repudiated August 25, 2005 physical capacity evaluation and reached the conclusion that there was no evidence to support that he had less than sedentary capacity. Hale went on to say that based on Dr. Seidel’s functional capacities review of May 3, 2006, Lanier should be able to function at a sedentary level for an eight-hour workday.
Lanier clearly needed the assistance of his disability attorney again. He appealed the decision to cancel his benefits on August 2, 2007. His letter noted that it was an error to rely on Dr. Seidel’s August 25, 2005 letter. To correct any confusion, he attached a new attending physician statement by Dr. Seidel dated February 21, 2007.
In this statement, Dr. Seidel limited Lanier’s abilities to one hour of sitting, standing, and walking. Lanier also provided a doctor’s note dated February 19, 2007, stating that Dr. Seidel had seen no improvement in Lanier health. Lanier also argued that MetLife was failing to take into consideration the information he had submitted in his March 6, 2006 appeal, including the outcome of the Social Security disability proceedings.
Just in case there were any questions, Dr. Seidel gave a clear description of Lanier’s physical limitations. He said that Lanier was only able to sit for 15 to 20 minutes before he had to get up, reposition, lie down or walk for a few minutes. Dr. Seidel said that Lanier was unable to work at his computer at home for more than 20 minutes due to the spasms that occurred in the back of his neck. The doctor stated that if Lanier sat for too long, the pain in his leg increased to the point where he had to go lay down. And finally, the doctor noted that Lanier had difficulty coping from an emotional perspective.
MetLife orders paper review of medical record. Doctors claim evidence does not support inability to perform sedentary work.
Lanier’s appeal was referred to medical consultants, Dr. Reginald Gibbons, a psychiatrist, and Dr. Sandar Pemmaraju, a physical medicine specialist. Neither doctor examined or spoke with Lanier, limiting their review to the medical record MetLife forwarded to them. While Dr. Gibbons, on August 21, 2007, acknowledged that the evidence supported Lanier’s continued complaints of depression and anxiety, the psychiatrist calimed it was inadequate to support functional limitations as a February 7, 2007. He criticized Dr. Seidel’s diagnosis and statement of limitations because there were no records of cognitive testing.
Dr. Pemmaraju likewise found on the same day that the medical information failed to support functional limitations significant enough to prevent Lanier from performing sedentary work. He criticized the fact that there was no formal capacity examination in the file.
MetLife claimed to have forwarded both of these doctor’s reports to Dr. Seidel for comment on August 24, 2007. Dr. Seidel responded on August 28, 2007, but it appears that MetLife failed to consider this letter before it confirmed its denial decision on September 6. The denial letter provided the following reasons for upholding the disability insurance reversal:
“[W]ith the medical records available for review, we concluded that the file did not contain any severity of impairment that resulted in functional limitations and restrictions preventing you from performing sedentary level of employment beyond February 6, 2007.
“In completing our review, we have determined that although you have medical conditions that support you having restrictions and limitations, you would be able to perform sedentary level work. Your symptoms and diagnoses would not prevent you from performing the alternate occupations identified with alternate employers. Therefore, our original decision to terminate your long-term disability benefits beyond February 6, 2007 was appropriate.”
Dr. Seidel’s letter of August 28 had disagreed with these conclusions. First, he stated that he had only received Dr. Pemmaraju’s review, thus he could not comment on Dr. Given’s review. Second, he noted that Dr. Pemmaraju’s review appeared to be based on an incomplete medical record, for it ignored many of the clinical findings. And finally, he explained that Lanier had not had a full functional capacity evaluation because no one was willing to pay for it.
Dr. Seidel, based on yet another examination of Lanier, reported that he had the following impairments:
- chronic cervical pain;
- chronic lumbar pain;
- left lumbrosacral radiculopathy;
- right cervical radiculopathy;
- dysfunctional sleep-wake cycle;
- objective reduced range of motion of the cervical spine, mild reduction in range of motion of the right shoulder, objective reduction in range of motion of the lumbar spine, and objective atrophy noted in the right upper extremity and left lower extremity;
- radiographic evidence of advanced severe degenerative joint disease of the cervical spine and lumbar spine in excess of what would be expected for his age.
MetLife ignores information supplied by attending physician.
By now, Lanier’s disability insurance attorney was vital. A September 20 letter from MetLife revealed that the disability insurance provider had not found Dr. Seidel’s letter convincing. The insurance company claimed that the letter failed to provide any additional objective clinical proof, thus they were not going to change their original appeal denial. As far as MetLife was concerned, Lanier had exhausted his administrative remedies.
Lanier made another effort to avoid taking his claim to court. To confirm his diagnosis with objective testing, Dr. Seidel ordered two more MRIs, one of his cervical spine and one of his lumbar spine. He also ordered electrodiagnostic testing of Lanier’s upper and lower extremities. Dr. Seidel sent the results of these tests to MetLife on October 1, 2007. MetLife received the information on October 9.
The nerve conduction study of upper extremities showed “no electro diagnostic evidence of bilateral median mononeuropathy or carpal tunnel syndrome,” yet it did show “electro diagnostic evidence of worsening bilateral ulnar neuropathy at cubital tunnel [but] no active axonal loss,” and “no electrodiagnostic evidence of bilateral cervical radiculopathy or plexopathy.”
The nerve conduction study on Ranier’s lower extremities revealed abnormalities. Ranier exhibited right L5-S 1 radiculopathy without active axonal loss. Larger polyphasia units were still present, indicating muscle or nerve damage, though the electrodiagnostic evidence failed to demonstrate sensory and motor peripheral polyneuropathy. There was no electrodiagnostic evidence of right lumbrosacral radiculopathy or plexopathy, as well.
The MRI results from September 18, 2007 showed minimal retrolisthesis and mixed biforarninal protrusions. A small central protrusion at the C4-C5 level slightly flattened the vental cord, slightly effacing the exiting right and abutting the exiting left C5 nerves. The MRI also found mixed biforaminal protrusions, with the right protrusions being greater than the left. The MRI observed a flattening of the right side of the ventral cord at the C5-C6 level. Mild retrolisthesis and mixed broad-based displacement with a slight flattening of the ventral cord at C6-C7 level that abutted the bilateral exiting C7 nerves was also noted. No abnormal enhancement was identified.
Disability insurance attorney files lawsuit to get disability benefits reinstated.
MetLife rejected the new information, claiming that the new test results had no bearing on their decision because their denial had been based on Lanier’s ability to work beyond February 7, 2007. As far as MetLife was concerned, test results from September 2007 could not support Lanier’s inability to perform sedentary work at the time they reversed their disability benefits decision. Lanier chose to exercise his rights under the Employee Retirement Income and Security Act (ERISA) and his disability attorney filed action on his behalf in U.S. District Court, Eastern District of Michigan, Southern Division.
How did his disability attorney present his case? Why was his challenge of MetLife’s benefits denial successful? We will consider this in our next article, MetLife Ordered to Reverse Denial of Long-Term Disability.