Met-Life Denies Benefits when Claimant Fails to Present Evidence to Support His Claim
The case of Dionisio Santana-Diaz v. Metropolitan Life Insurance Company (MetLife) demonstrates how important it is for claimants to present as much medical evidence as possible to the plan administrator who is evaluating the claim for Long Term Disability (LTD) benefits. Despite many opportunities to do so during the initial evaluation and subsequent administrative appeal, Santana failed to provide the requested medical documentation to support his claim.
After working for 25 years as an accountant for Shell Chemical Yabucoa, Inc., Santana’s request for LTD benefits due to a mental disorder and depression was approved. Met-Life paid him benefits for the Plans limited 24-month benefit duration period for mental health disorders beginning in November 2008.
In April 2010, MetLife sent a letter to Santana telling him his benefits would be terminated in November 2010 unless he provided objective medical evidence establishing that he was eligible for LTD benefits on a basis that was not due to a mental disorder. Santana did not respond. As a result, in November 2010, he received a letter from MetLife telling him his benefits had been terminated. He was also informed he had the right to appeal.
The Administrative Appeal: Santana Failed to Present Evidence to Support His Claim
Early in the appeal process, MetLife’s hired physician reviewer consulted with Santana’s primary care physician, Dr.Catoni, who at first said that Santana’s primary problem was psychological. Catoni then added that Santana had been diagnosed with peripheral neuropathy and could not walk long distances and could not raise his arms far above his head due to arthritis in his shoulders. Dr. Catoni did not give an opinion on how these conditions would prevent Santana from doing his job.
MetLife’s reviewing physician then reported that he did not find any objective evidence in the medical file to support either one of these diagnoses. There was no evidence of any physical exam documenting them, no office visits, and no test results. There was nothing in the record to even suggest how these conditions would impair Santana’s ability to work as an accountant.
MetLife faxed this report to Dr.Catoni. Dr. Catoni responded by drawing attention to an office note from February 25, 2011, in which he contended that the diagnosis of peripheral neuropathy was well-documented. The note was simply Dr. Catoni’s conclusion that Santana suffered from diabetic peripheral neuropathy. The doctor sent additional medical records to MetLife.
The additional medical records did not contain any additional documentation of test results or objective evidence supporting the diagnosis of diabetic peripheral neuropathy, or any evidence about how that diagnosis led to any physical impairment or restrictions and limitations on work abilities. Therefore, MetLife upheld its previous termination of benefits. Santiago then filed an ERISA lawsuit.
ERISA Lawsuit: Court is Limited to Review of Administrative Record and Will Not Consider Any New Evidence
When federal district courts are faced with an ERISA lawsuit, they are legally bound to consider only the evidence in the administrative record that was before the Plan administrator when the decision was made. The Court will not consider any new medical tests, any new notes from doctor’s office visits, any testimony from anyone, including doctors or employers.
Since Santana had not presented the requested evidence during the appeal to MetLife, so there was no documentation of the diagnosis of diabetic peripheral neuropathy other than Dr. Catoni’s opinion, and he presented no evidence of how that condition would impair his ability to work, the Court was essentially hamstrung. It almost had no choice but to uphold the decision by MetLife.
Contrary to Santana’s Assertion, MetLife Informed Him of Evidence It Required, But He Failed to Provide It
The federal district court initially determined Santana had failed to prove by a preponderance of the evidence that he was entitled to LTD benefits, and that decision was upheld by the United States Court of Appeals for the First Circuit. MetLife had informed Santana that he had to prove:
1) That he had a qualifying condition; and
2) That the condition caused him to be disabled under the plan.
Since Santana repeatedly failed to provide the Plan that evidence, the Courts decided that he had not met his burden of proving by a preponderance of the evidence that he suffered from a qualifying condition, and that that condition prevented him from performing the duties of an accountant. Therefore, he was not entitled to LTD benefits.
This case was not handled by our firm. If you have experienced a denial of LTD benefits, or benefits you were receiving have been terminated, we urge you to contact one of our attorneys at Dell & Schaefer. We offer a free consultation where we will review your case and determine what evidence needs to be submitted for your administrative appeal that will give you the best chance of winning your LTD benefits. There are no guarantees in the law, but we work to provide as much evidence as possible to support your appeal and to comply with all evidentiary requirements of your disability insurance company.
Resources to Help You Win Disability Benefits
Get Your MetLife Disability Application Approved
Prevent a MetLife Disability Benefit Denial
Negotiate a MetLife Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Policy Holder Rating
Q: Would any new disabling conditions be considered by Metlife when considering whether or not to continue my benefits?
Q: Do I have to sign and return MetLife's authorization to disclose my info in order to continue my claim?
Senior Global Tax Director for billion dollar worldwide industrial company is again receiving disability benefits from MetLife after Appeal by Attorney Alexander Palamara
Reviews from Our Clients
Very satisfied with the work of this team. Took well care of my case and took all the necessary time to be responsive and attentive when I had questions. Guided me through recovery and returning to normalcy. All thanks to Jason & Tabitha, thank you!
I’m extremely satisfied with the experience I have had with this firm from day one. The lawyer who has handled my case, Alex, is very efficient and attentive to all my questions and concerns. They are always aware of how my case has gone and they care about my health. I feel optimistic with them because they are very attentive during the process of my claim. I would not hesitate to recommend families and friends if in any situation they need their services. Kathleen as well has been very well and assisted me with this case. I highly appreciate everything they have done for me.
It’s unfortunate when disability insurance companies come after older disabled policyholders just to help their bottom line. It can be a living nightmare the damage they can do to a family. Dell Disability Lawyers are polite, understanding and knowledgeable. They call you back and answer any question you have no matter how unimportant it can be. The amount of stress they took off of myself and family was incalculable. I recommend them highly to take care of any disability case whether it be filing for benefits or reversing a claim decision. They are outstanding.
I could not have been happier or more appreciative of the hard work they performed on my behalf. I was well briefed on my case and it was closed in a timely manner with a financially successful resolution.
Mr. Symonds and Sonia as well as everyone else we have worked with throughout this process have been very helpful, professional and caring to our situation. We are very thankful to have this great team on our side.
Without them my LTD company was dropping my plan with me still suffering from my accident, even with doctor’s statements I’m still disabled. The LTD company didn’t want to advance my policy to the next stage of years of pay. Dell Disability Lawyers saved my policy, and helped to enforce the LTD company’s own policy (for its policy holder, me) that I would be covered still under the LTD policy I had paid for at my previous job, when my accident occurred. These lawyers know what they are doing and can help you too. LTD companies will try to drop you when you still need coverage just because they don’t want to pay on your policy anymore. Don’t let them break contract with ya because they are trying to get out of it. Hit em with legal action to ensure the continuation of your policy you paid for. Dell Disability worked very well for me and continue to do so.
I was denied long term disability benefits from The Hartford after being on it for years. I found Dell Disability Lawyers after doing research online. In a matter of days they responded and explained to me everything that would be done. Dell Disability Lawyers were able to settle my suit against The Hartford very quickly and responded to me quickly. I would definitely recommend this team of lawyers for anyone that is fighting for their disability insurance.
I have had nothing but a great experience with Dell Disability Law Firm. Mr. Alex Palamara and his team went above and beyond my expectations. They will respond to emails and phone calls in a timely manner. Thank you once again for taking my case.
This law firm is the best so far. MetLife denied me two times, they appealed two times for me and they won of course. So if you are on disability and want a chance at winning your case use this firm Dell disability lawyers, kind courteous understanding and they get the job done. You won’t be disappointed.