Marriott Sales Executive With a Failed Total Shoulder Replacement Wins Florida MetLife Long-Term Disability Insurance Appeal After Paper-Review Termination
MetLife paid our client’s long-term disability benefits for nearly three years — and then decided he could go back to work, based on a report written by a doctor who never once laid eyes on him. Our client, a Sales Executive for Marriott Vacations Worldwide in Florida, had spent years and eight surgeries trying to rebuild a right shoulder that never healed, and he was still in daily pain from a failed shoulder replacement and related neck and nerve conditions when the checks stopped.
This is a maneuver we have seen and beaten many times: an insurer approves a claim, pays it well past the point where the standard toughens, and then manufactures a reason to walk away — almost always a paper review that quietly ignores the evidence the company once relied on. We built the appeal around objective functional testing that MetLife’s own reviewer could not honestly dispute, and MetLife reversed course and reinstated every dollar of benefits.
What follows is worth understanding for anyone whose benefits have been terminated after years of payments, because the weaknesses that sank MetLife’s denial are the same ones that run through file-review terminations across the industry. If MetLife or any other disability insurance company has cut off your benefits, you can speak with one of our disability insurance attorneys anywhere in the country for a free consultation, and we charge no fee unless we recover your benefits.
Table Of Contents
- 1. Why this case matters for every MetLife claimant
- 2. The termination MetLife built on a doctor who never examined him
- 3. Why “any occupation” was really a $240,000 question
- 4. The functional capacity evaluation MetLife could not explain away
- 5. The contradiction at the center of MetLife’s paper review
- 6. MetLife reverses and reinstates the benefits
Why This Case Matters for Every MetLife Claimant
We have represented long-term disability claimants with shoulder disorders for decades, and a handful of lessons from this case apply to almost anyone whose MetLife benefits have been terminated.
- A paper review is not evidence that you have recovered. MetLife cut our client off on the strength of a file review — an evaluation in which a physician the insurer hires reads the paperwork and offers an opinion without ever examining the claimant. No exam, no new imaging, no phone call to a treating doctor. When a denial rests on nothing but a reviewer’s reading of old records, that is an assumption, not a finding.
- The insurer’s own words are often the strongest argument against it. MetLife’s reviewer conceded in writing that our client’s shoulder remained structurally damaged and functionally limiting — and then assigned restrictions that assumed a normal, working arm. You often do not have to look outside the file to defeat a denial like that; the contradiction is already inside it.
- A valid Functional Capacity Evaluation is the most powerful answer to a file review. A Functional Capacity Evaluation is a standardized, hands-on test that measures how long and how consistently a person can actually sit, stand, grip, lift, and reach across a workday. Real-world, effort-verified testing gives a non-examining reviewer very little to push back on — which is exactly why it works.
- “Any occupation” does not mean “any job you can imagine.” After two years, most group policies stop asking whether you can do your own job and ask instead whether you can perform any gainful occupation. For a high earner, that question carries a wage floor — and a job that pays a fraction of your former income does not count. Insurers routinely skip that part.
- Benefits an insurer paid for years are evidence in your favor. MetLife approved this claim and paid it well past the point where the standard hardened to any occupation. An insurer that reverses itself after years of payments has to explain what actually changed. Here, nothing had — except the conclusion MetLife wanted to reach. Understanding how these denials are assembled is also the best way to keep a MetLife disability claim from being denied in the first place.
The Termination MetLife Built on a Doctor Who Never Examined Him
MetLife did not deny this claim at the outset. It approved it, agreed our client was disabled, and paid benefits continuously for nearly three years — a period that carried well beyond the point, at the 24-month mark, when the policy’s standard shifted from his own occupation to any occupation.
In other words, MetLife had already determined that our client could not perform even the least demanding full-time work. Then, without a single new examination, it decided the opposite.
Because this coverage came through his employer, the claim was governed by ERISA, the federal law that controls most group disability plans and requires a claimant to complete a written administrative appeal before a denial can be challenged in court. That appeal is the one real opportunity to build the record. So attorney Alexander Palamara built it.
The medical reality was not close. Our client’s right shoulder had been operated on eight times and never stabilized. He carried diagnoses of primary osteoarthritis of the right shoulder (ICD-10 M19.011), adhesive capsulitis of the right shoulder (M75.01), chronic pain syndrome (G89.4), and cervical radiculopathy (M54.12) — nerve irritation in the neck confirmed by a positive Spurling’s sign, the clinical test in which pressure on the head reproduces radiating arm pain.
A CT scan showed lobulated lucencies along the glenoid component of his shoulder replacement, raising concern for osteolysis — bone quietly dissolving around the implant. Glenoid component loosening and failure is the most common long-term complication of a total shoulder replacement and a frequent reason the surgery has to be redone.
His treating orthopedic surgeon had already scheduled a major revision arthroplasty, with bone grafting and a possible antibiotic spacer, to address a loose glenoid component, bone loss, and possible infection — the mechanical loosening of a right shoulder prosthesis (ICD-10 T84.038A) in a patient with a documented artificial shoulder joint (Z96.611).
None of that stopped MetLife’s file reviewer, orthopedic surgeon Dr. Arash Yaghoobian, from concluding that our client could work full time. Dr. Yaghoobian never examined him and never called a single treating physician. From the paperwork alone, he assigned a set of restrictions that would let almost anyone keep working:
- Unrestricted sitting, standing, and walking
- Unrestricted reaching at desk level with the right (dominant) arm
- Unrestricted fine manipulation and simple and firm grasping with both hands
- Only occasional overhead and below-waist reaching with the right arm
- Occasional lifting, carrying, pushing, and pulling up to ten pounds on the right
- Full-time, sustained work capacity
A Vocational Review That Simply Agreed — and an SSA Award MetLife Ignored
MetLife then handed the file to a vocational consultant, who did exactly what the medical review invited: agreed. The consultant declared that our client retained a “sedentary to light” capacity and could return to his own occupation, without ever grappling with what that occupation actually demanded. That is how a paper-only denial becomes a house of cards — one non-examining opinion propping up another.
MetLife also had, sitting in its own file, a Social Security Administration Notice of Award finding our client disabled on substantially the same medical evidence. The company asked him to repay the resulting offset. It did not bother to obtain or review the SSA file before terminating his benefits.
An insurer that wants the money a disability award generates but ignores the reasoning behind it is not conducting the full and fair review ERISA requires. We recently dismantled the same approach for a MetLife any-occupation termination built entirely on a non-examining paper review — a denial we also reversed on appeal.
Why “Any Occupation” Was Really a $240,000 Question
To understand why MetLife’s vocational conclusion was hollow, you have to understand the standard it was applying. Most long-term disability policies use two definitions of disability in sequence.
For the first 24 months, benefits are paid if you cannot perform your own occupation. After that, the standard changes: under the any-occupation standard, benefits continue only if you cannot perform the duties of any gainful occupation for which your training, education, and experience qualify you.
What insurers often bury is the word gainful. Under this policy, “gainful” was defined by a wage floor — our client had to be unable to earn more than 60% of his predisability income. With predisability earnings of roughly $400,000 a year, that put the threshold at about $240,000.
The question was never whether he could theoretically sit at some job somewhere. It was whether a man who could not reach, grip, or type with his dominant arm could find and sustain work paying a quarter of a million dollars a year.
His occupation as a Sales Executive for Marriott Vacations Worldwide was not desk-bound busywork. It was a high-pressure, commission-driven role that ran on sustained computer and tablet use, constant client engagement, repetitive upper-extremity activity, and heavy travel to road shows, resorts, and cruises.
His pay rose and fell with his productivity. Take away his ability to reach and use his dominant hand for more than a few minutes at a time, and the very engine of his income was gone. MetLife’s “sedentary to light” label never touched any of this.
The Functional Capacity Evaluation MetLife Could Not Explain Away
Against a paper review, we did the one thing a file reviewer cannot argue with: we put our client’s body to the test. He agreed to a Functional Capacity Evaluation with a neutral, licensed occupational therapist — roughly three and a half hours of hands-on, standardized measurement of what he could actually do across a simulated workday.
Effort That Could Not Be Faked
The first thing a good evaluation establishes is whether the person is genuinely trying, and this one left no doubt. The therapist documented good test-retest reliability on repeated strength and grip measurements, heart-rate increases exceeding ten beats per minute during exertion, and changes in movement velocity and body mechanics when our client was pushed past his tolerance. In plain terms, those are physiological responses a person cannot manufacture on command.
Just as tellingly, his strength readings held steady after testing rather than collapsing — the signature of someone giving maximal effort, not someone limiting himself. The evaluator confirmed the results were valid, maximal, and reliable.
What the Testing Actually Found
The measured limits were devastating to MetLife’s position:
- He could not sit for two hours continuously or for up to six hours total in a workday — only about thirty minutes at a stretch before he had to reposition.
- Standing and walking were limited to roughly fifteen minutes at a time and no more than two hours across a day.
- He could use his dominant right hand for grasping and fingering only occasionally — about ten minutes continuously and an hour and a half total per day.
- He could not perform overhead reaching with the right arm at all.
- Forward reaching with the right arm was occasional only, with right-sided guarding and rising pain throughout.
- Pushing and pulling were capped at about ten pounds.
Below Even a Desk Job
Those numbers matter because of where they fall on the government’s own scale. The Department of Labor defines sedentary work — the least physically demanding category of full-time employment — as requiring the ability to sit for about two-thirds of an eight-hour day.
A person who cannot sit even that long, and who cannot use his dominant hand for sustained gripping or typing, is what disability examiners call less than sedentary — unable to hold even a desk job, let alone the demanding sales role our client once performed. The evaluator’s conclusion was blunt: our client was “unable to work at this time.”
That is the entire ballgame in an any-occupation case. If you cannot meet the sitting and hand-use requirements of sedentary work, there is no lighter occupation to send you to. We made the identical point on behalf of a quality-assurance manager sidelined by a disabling shoulder injury and a cascade of related conditions, whose benefits we also won back under the any-occupation standard.
The Contradiction at the Center of MetLife’s Paper Review
The most powerful part of this appeal did not come from our evidence. It came from MetLife’s. Across three separate reviews, Dr. Yaghoobian conceded, in writing, that the updated records “confirm ongoing structural dysfunction of the right shoulder,” that our client’s pain and range of motion remained unchanged, and that his condition “remains functionally limiting.” He agreed restrictions were warranted on an ongoing basis and that reassessment should wait until after the revision surgery.
And yet, in the same breath, he assigned restrictions that presume a healthy arm. You cannot call a shoulder functionally limiting — a shoulder with a failed replacement, documented osteolysis, chronic pain, and breakaway weakness — and then, without explanation, declare that same right arm capable of unrestricted fine manipulation, unrestricted firm grasping, and unrestricted reaching at desk level.
Those conclusions cannot coexist with the treating surgeon’s permanent restrictions, which limited gripping and lifting with the right arm to two pounds, barred any use of the arm at or above shoulder level, and prohibited repetitive use of the right upper extremity altogether.
Desk-level reaching is not a neutral activity; it demands sustained shoulder stabilization and endurance, precisely the functions a failed arthroplasty destroys. When a reviewer’s own restrictions contradict both anatomy and the record, the review is unreliable on its face.
The refusal to pick up the phone made it worse. Dr. Yaghoobian wrote that “there was no need to speak to a treating provider to obtain further clarification” — while simultaneously overriding the permanent restrictions of the surgeon who had performed the operations, visualized the joint, and followed our client for years.
When a file reviewer chooses to reject the judgment of the one physician who actually operated on the patient, direct physician-to-physician contact is not a courtesy. It is the minimum of a fair review. Skipping it, then branding the surgeon’s restrictions “too restrictive,” is how you spot a review built to reach a conclusion rather than to find one.
MetLife Reverses and Reinstates the Benefits
We put the contradiction to MetLife directly: if the Functional Capacity Evaluation was valid and consistent with the medical record — and MetLife’s own appeal-stage consultant conceded that it was — then its findings could not be selectively discarded simply because they proved disability. Validity is not a switch an insurer gets to flip on for the parts it likes and off for the parts it does not.
MetLife agreed. After reviewing the objective testing, the treating-source evidence, and the vocational analysis, the company changed course. In its correspondence, MetLife confirmed, “After reviewing your request, we have changed our original decision,” and forwarded the claim for reinstatement and payment of the benefits it had wrongly withheld.
If MetLife or any other disability insurance company has terminated your benefits after a paper review — especially one that leans on a doctor who never examined you — do not assume the fight is over.
Under ERISA, you generally have a limited window, often 180 days, to file an administrative appeal, and that appeal is your one chance to build the record before any federal lawsuit becomes possible. Missing it can cost you the case. We would rather you not face that deadline alone.
Our disability insurance attorneys have represented tens of thousands of claimants nationwide since 1979 and have recovered more than $2 billion in disability benefits from every major carrier. To speak with one of our lawyers about your denial or termination, contact our office for a free consultation. We represent clients across the country, and you pay no fee unless we recover benefits for you.
