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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There are 3 comments

  • Jenny,

    We have never heard of any disability policy which requires you to be confined to a house or bed. You are allowed to leave. You must be unable to work and satisfy the definition of disability in your policy.

    Gregory DellJun 4, 2013  #3

  • I am 40 years old. in 2010 while walking to my vehicle I experienced a severe pain to my lower back. It felt like a knife was put in my spine and twisting. Since I was very athletic and worked out I thought possible tore a muscle. MRI showed I had a tear on my s1 disk and some disk degeneration on l4-l5. I had used all my FMLA time due to gi issues and my child with severe chronic asthma. I have MetLife, they approved STD no problem. My work pays for our STD and I pay for my long term. Since I exceeded MetLife I was already put on disipline action but they advisor did me a favor this time and allowed my leave that was approved by their covered STD. My work confines employees to home on STD, but union contract states confined unless circumstances given by Dr. with a note which notes my work and union continued to say MetLife had to approve me to not be confined after a month of arguing MetLife case manager called my work and union and advised them that MetLife does not confine me while recovery from surgery except from leaving the state my work advised they would let me walk one a day and I was required to call when I left and when I returned.

    I am now again in a similar issue I uave exhausted my FMLA going back and forth with medical testing from upper gi issues and my back. A recent MRI has shown I have another tear in my s1, disc degenerative disease on l4-l5 and spinal stenosis. I have a new surgeon and since the pain is so intense and non stop even though I am now taking up to 120mg a day of morphine with muscle relaxers, my surgeon has advised I am at the point of needing a 3 level spinal fusion done which can result in 6-8 months of recovery. MetLife again has advised under my STD plan I am not confined.

    Is it legal for a company to confine someone on STD to home and doctor? I ask this because my chiropractor said the fact that during reccovery I had limited movement it may have caused more issues. 6 months is a long time not to leave your house. Everyone I talk to says they never heard such a thing. My union didn’t even know MetLife was not confining me.

    I fare if I have this surgery, which I am, I have no choice, even medicated my pain is so severe I can not work… I sit all day. I can do some things like go to my son’s games for 1-2 hours or see a movie for 1-2 hours. But 8 hours in a chair is too much. Recovery often includes slowly getting back to normal daily activities.

    So my overall question is if MetLife is your company paid benefit plan and due to years of service my STD is paid and my company covers my STD with MetLife. Can an employer confine you when MetLife who approved your STD does not? My company does not confine me while on LTD since I pay for it. But in every case I’ve discussed with Drs they advised even if they believe there is a chance of being out 8 months which qualifies as LTD through my employer. Drs advised they are required to put me out 3 months at a time so I come in at 3 months then they put me out for more ect. Is it legal to confine someone to home and Dr. only for 6 months when MetLife is the STD and they don’t confine you?

    Jenny GravesJun 3, 2013  #2

  • That’s sad considering that the plaintiff had a real disability. Makes me want to check the fine print for everything!

    Lily JamesJun 13, 2012  #1

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