Advisor Wins Metlife LTD Insurance Appeal for Chronic Pain

The road to long term disability benefits is far too often a difficult and arduous journey for many insured. Our client’s story is a testament to the lengths an insurance company will go in an attempt to avoid its obligation to pay benefits under a disability policy. I first wrote about my client’s battle to secure the remaining month of his short term disability benefits on account of a multitude of medical conditions, which included Restless Leg Syndrome, Insomnia, Chronic Lumbar and Cervical Pain, Cognitive Impairment, Depression and Anxiety. Following a successful appeal MetLife approved our client’s remaining month of short term disability benefits. However, in doing so, they did not initially award Long Term Disability benefits. Our client’s claim was then sent to MetLife’s long term disability department for further review, where it took an additional month to make a decision as to our client’s entitlement to long term disability benefits. Despite a plethora of medical evidence supporting disability from a physical impairment, MetLife determined that our client was only disabled on account of his diagnosed Mental Health conditions of Depression and Anxiety, which according to his policy has a maximum benefit period of 24 months of payment.

Limitations for Mental Health Conditions

More often than not a physical illness or injury that leads to disability has a secondary component of depression, anxiety or some other mental health condition. Secondary, by nature, does not mean primary, but rather “but for x condition, the mental health condition would not be present.” It is not uncommon for an insurance carrier to ignore physical evidence of disability in favor of a mental health condition as a means to limit its liability to an insured under the policy.

Almost every ERISA governed Long Term Disability policy has some type of limitation for disabilities caused by a Mental Health Condition that typically, limits claims for benefits caused by a Mental Health Condition to a maximum of 24 months. Each disability carrier defines Mental Health Condition and/or the limitation differently, and thus a close examination of the particular language in an applicable policy is crucial.

With a potential maximum payment period of 24 months it is obvious to see the advantage to an insurance company in making a determination of disability based on a condition subject to a limitation in the policy. Needless to say, this determination is always to the detriment of the insured – as was the case with our client.

Do Not Wait to Challenge a Decision to Limit Benefits

All too often an insured will wait to challenge an insurance company’s position that a claim is subject a limited pay period until after the limited benefit period ends. By waiting for the expiration of the limited benefit period the insured is forced to appeal a denial of benefits while no money is forthcoming from an insurance company. When time and money is of the essence action must be taken quickly. As soon as MetLife approved our client’s claim on account of a mental health condition and benefits were being issued, we set out immediately to ensure MetLife would make a determination that our our client’s claim was in fact due to the multitude of physical medical conditions he suffered from. All the while our client was still collecting monthly disability benefits from MetLife based upon its prior determination of entitlement due to his mental health diagnoses. With additional evidence to support his claim for physical disability, to include a confirmed diagnosis of Lyme’s disease, MetLife notified our office that it had determined our client was in fact disabled on account of his physical medical conditions and that it was removing the 24 month mental health limitation it had placed on his claim.

Is Your Claim Being Wrongfully Subjected to a Limited Benefit Period?

If your insurance company is placing your claim into a limited benefit period, such as those for Mental Health conditions, or what it deems to be a “Self-Reported Symptom” condition, don’t wait to challenge their position. Please feel free to contact our office to discuss how we can assist you in collecting the benefits you are entitled to.