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MetLife Disability Claim Limited to 24 Months of Benefits Results in ERISA Lawsuit

North Dakota Court Affirms MetLife Denial of Disability Benefits

On June 5, 2012, the U.S. District Court for the District of North Dakota granted Metropolitan Life Insurance Company’s motion for summary judgment against a man who had filed an ERISA lawsuit after being denied continued disability benefits. The issue with the case did not stem on whether the man was disabled. In fact, MetLife was not actually making the argument that he was not disabled. Instead, MetLife agreed that he was disabled, but it argued that due to certain policy language it would not be required to pay disability benefits to the claimant anymore.

The Plaintiff had worked at BNSF Railways since 1972. Due to his employment, the plaintiff was covered under Short Term and Long Term Disability Insurance Policies issued by MetLife. On February 12, 2007, the plaintiff was forced to leave work due to degenerative disc disease. He filed an application for short term disability benefits and was approved. He was paid STD benefits until the policy expired. The Plaintiff then filed for and was approved for long term disability benefits. His long term disability benefits began on August 13, 2007.

MetLife Long Term Disability Policy Limits Benefits to only 24 Months of Payments

As the Plaintiff’s claim was pending one of his treating physicians completed an “Attending Physician Statement” for MetLife. This doctor listed the Plaintiff’s diagnoses as “degenerative disc disease and radiculopathy. ”

In April of 2009, MetLife informed the Plaintiff that his long term disability benefits would be ending in August 2009 under the “Limitation For Disabilities Due to Particular Conditions” language found in his policy. This “Limitation” specifically states:

You are covered for 24 months of Disability during your lifetime if you are Disabled due to a:

2. Neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:

  1. seropositive arthritis;
  2. spinal tumors, malignancy, or vascular malformations;
  3. radiculopathies;
  4. myelpathies;
  5. traumatic spinal cord necrosis; or
  6. myopathiese.

Relying on this language, MetLife sent the Plaintiff a letter dated May 19, 2009 which informed him that additional benefits would not be payable beyond August 12, 2009 when 24 months of benefits will have been paid.

The Plaintiff filed a timely administrative appeal challenging MetLife’s determination. This appeal proved unsuccessful as MetLife’s “Independent Physician Consultant” spoke with the Plaintiff’s treating physicians who confirmed the lower extremity EMG/NCV study was negative for evidence of radiculopathy, peripheral neuropathy, or focal neuropathy. MetLife therefore concluded that the Limited Benefit Condition provision prohibited continued benefits and denied the appeal. The Plaintiff was therefore forced to file a lawsuit.

Radiculitis v. Radiculopathy: Does it Really Matter?

The Judge assigned to the lawsuit upheld MetLife’s decision. The Court found that the physical evidence provided by the Plaintiff and his physicians only showed radiculitis related to degenerative lumbar disc disease and not radiculopathy. The Court showed that “radiculopathy is a ‘disease,’ while radiculitis is an ‘inflammation'” and the court concluded these terms were not interchangeable. The Court, therefore, concluded that MetLife’s interpretation of the Plan and its denial of the Plaintiff’s claim was reasonable. The Court granted MetLife’s motion and the Plaintiff/Claimant lost his lawsuit.

It must be noted that the outcome of this ruling is specific to the facts of the case and the language of this particular policy. This case was not handled by Attorneys Dell & Schaefer. However, this decision begs the question of whether other testing could have been done to show that the Plaintiff suffered from radiculopathy or any other disabling condition not subject to the limiting policy language. Contact our firm for a free consultation to discuss your disability insurance claim.



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