Teacher's Disability Benefits Reinstated by MetLife
Our client, a former elementary school teacher in Broward County Florida was forced to stop working to undergo lower back surgery with a fusion. Prior to the scheduled surgery he pre-emptively filed a short-term disability claim with MetLife, which was approved prior to his surgery. Despite the surgery being a “success”, it did not alleviate his pain completely and he continued to experience radiating pain, tingling and numbness into his lower extremities. His claim transitioned from short term disability and into long term disability as updated CT scans indicated that the fusion was healed and not yet fully solidified. MetLife approved his claim for long term disability policies but quickly thereafter began aggressively reviewing his claim, which culminated in a denial of benefits less than 1 year after his surgery. Our client contacted our office shortly after receiving the denial letter.
Does MetLife Have to Examine You Before Denying Your Disability Benefits?
No. MetLife, or any insurance company, is not obligated to have you physically examined before denying a disability benefit. In our client’s case, MetLife’s denial was predicated on a paper file review performed by a hired consultant who reviewed the available medical records and determined there was no evidence to support that our client suffered from a medical condition or combination of conditions of such severity to warrant placement of any restrictions or limitations as to his activities. Before denying the claim, MetLife didn’t even wait for a response from our client’s doctor as to its doctor’s report before terminating the benefit. With a one-sided paid for opinion, MetLife determined our client was no longer eligible for disability benefits.
Do I Have To File An Appeal With MetLife After They Denied My Benefits?
If your coverage is through an employer provided policy, yes- you will need to file an administrative appeal with MetLife. Our client was unsure of the steps that had to be taken but after his experience dealing with MetLife he knew he did not want to fight them on his own. In our initial call I explained to him that MetLife only allowed for one level of appeal prior to the filing of a lawsuit. Unlike most people with MetLife policies provided by their employers, our client’s policy was not governed by the federal law, ERISA, as he worked for a government entity. For reasons discussed throughout our website, not being subject to ERISA has many benefits should a lawsuit be filed, but it didn’t make the appeal process any less important.
Building The Case For Disability Benefits
In reviewing our client’s claim, it was apparent that we had multiple obstacles to overcome. First and foremost, we had to establish that our client was disabled from performing the material duties of his regular occupation as a elementary schoolteacher. Second, since our client was not likely to go back to work, we also had to prepare the claim for the 24 month change in definition of disability from the inability to perform his own occupation to the inability to perform any occupation as defined in the policy. Finally, his policy with MetLife contained a 24-month limitation for neuromusculoskeletal/soft tissue disorders, which would seek to limit his maximum monthly benefits to 24 months total, unless he met one of the enumerated exceptions to the limitation, in his case- evidence of radiculopathy.
The first step in establishing the presence of restrictions and limitations that would support his inability to work as an elementary school teacher necessitated a Functional Capacity Examination (FCE). The FCE would form the basis of undermining the opinion of MetLife’s file review doctor and provided additional objective evidence for our client’s doctors to utilize when commenting on our client’s medical condition. The FCE also served to help establish our goal of preparing our client’s claim for the 24-month transition in definition of disability from “own” to “any” occupation.
The FCE results indicated that our client would not be able to meet the physical demands of his prior work, but also that he did not have a full gamut of sedentary physical ability to perform any occupation on a full-time basis. After receiving the report, we sent requests for opinions and statements from seven of our client’s doctors. Whereas MetLife would rely on one doctor who never met our client or spoke to one of his doctors, we were prepared with an overwhelming amount of medical support. To address the concerns as to the 24-month limitation contained in the policy as it related to our client’s medical condition, we had him undergo EMG and nerve conduction studies with his doctors to establish the presence of radiculopathy and in turn get around the limitation.
Within 45 days of submitting the appeal, MetLife advised our office that it was overturning its denial and reinstating our client’s claim for benefits. Although our client’s claim has not made it to the 24 month change in definition of disability, we are well prepared to confidently argue his ongoing entitlement to benefits when MetLife begins that review.
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