MetLife writes one of the most restrictive 24 month limitations in its ERISA governed group disability policies for medical conditions that they deem fall under the definition of “Neuromusculoskeletal and Soft Tissue Disorder.” The language commonly used defines the term to mean:
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 the joints and adjacent muscles, unless the Disability has evidence of (a) seropositive arthritis; (b) spinal tumors, malignancy, or vascular malformations (c) radiculopathies (d) myelopathies (e) traumatic spinal cord necrosis or (f) musculopathies.
This language is obviously intended to limit MetLife’s responsibility to pay benefits for the overwhelming majority of pain related conditions. However, in the recent case of Arquilla-Romeo v. Metropolitan Life Insurance Company an Ohio Federal Judge ruled that MetLife was misapplying the limitation and acted arbitrary and capricious in terminating the plaintiff’s claim based on the interpretation MetLife chose to apply.
Many ERISA governed group disability policies contain discretionary clauses that grant the insurance company the exclusive right to interpret the terms and conditions of its policy. In denying Arquilla-Romeo’s claim, MetLife did just that by determining that her disability, resulting from a lumbar fusion was limited to 24 months under the Neuromusculoskeletal and Soft Tissue Disorder limitation contained in the policy. In many cases the court will defer to the insurance companies interpretation of its policy to the detriment of the insured. However, as this case shows this is not always the case.
The Semantics of “And” and “Or”
In arguing motions to the Court it became evident that MetLife was interpreting and subsequently applying the limitation to mean a Neuromusculoskeletal “OR” soft tissue disorder would be limited to a maximum benefit period of 24 months. However, the Court was quick to point out that MetLife, when drafting the policy, did not accomplish writing a policy that created the interpretation it was applying. The Court noted that MetLife consistently ignored one of the most basic premises of contract interpretation – that the word “and” and the word “or” are not interchangeable. In applying this premise, the Court states that it must give meaning to every word in the contract and “may not engage in an interpretation that renders terms meaningless.”
Based on the foregoing the Court ruled that the only reasonable interpretation of the phrase “neuromusculoskeletal and soft tissue disorder” is to conclude that there are two parts: (1) that the disorder affects the neuromusculoskeletal system AND (2) that the disorder affects the soft tissues. Any other interpretation would be unreasonable and ignore the language MetLife chose to select. In turn, the Court found MetLife’s denial of Arquilla-Romeo’s claim to be arbitrary and capricious and remanded the claim back to MetLife to render a decision in accordance with the Court’s ruling.
(NOTE: In remanding the case, the Court did NOT award Arquilla-Romeo her disability benefits, but rather forced MetLife to conduct further review. As such, there is no guarantee that MetLife will ultimately change its decision to deny her claim).
How Does This Affect You and Your MetLife Policy?
As a large percentage of MetLife policies contain the above noted policy provision and the fact that many claims for benefits are made due to pain related conditions, this ruling could be used as a strong argument that benefits for conditions that MetLife would normally determine fall into the limitation should not be terminated at the 24 month mark. That being said, this ruling does not serve as a guarantee that MetLife will not find a way to deny your claim for benefits for an alternate reason. If you have a claim with MetLife and they are asserting that it is subject to a Neuromusculoskeletal and Soft Tissue Disorder limitation of 24 months, please feel free to contact our office to discuss how we may be able to assist you in fighting for benefits beyond the 24 month limitation period.
Attorneys Dell & Schaefer did not represent Ms. Arquilla-Romeo, nor had any involvement in any stage of her claim for benefits.
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