MetLife Long-Term Disability Denial Of Disabled Yamaha Motors Corporation Manager With Genetic Disorder Is Reversed Following ERISA Appeal
Author: Attorney Cesar Gavidia
“The ability to perform with reasonable continuity the substantial and material acts necessary to pursue his usual occupation”, was the definition of disability set forth under Yamaha Motor Corporation’s Long-term Disability Plan, and the primary question in our client, Mr. B’s, long-term disability claim. Metropolitan Life Insurance Company (“MetLife”), the disability insurance company which both administered and funded the Yamaha Long-term Disability Plan, had the principal fiduciary responsibility to fairly evaluate and determine whether Mr. B qualified for long term disability benefits under this definition.
Mr. B had spent a number of years working for Yamaha, and had worked his way up to becoming an Assistant Department Manager for the corporation. Mr. B was also born with a rare genetic disorder known as Multiple Hereditary Osteochondrosis, also known as, Hereditary Multiple Osteochondromas (“HMO”).
Hereditary Multiple Osteochondromas, A Rare And Painful Genetic Disease Causes Disability
HMO is characterized by growths of multiple osteochondromas (benign cartilage-capped bone tumors that grow outward from the metaphyses of long bones). Osteochondromas can be associated with a reduction in skeletal growth, bone deformity, restricted joint motion, shortened stature, premature osteoarthritis, and compression of peripheral nerves.
Mr. B had been diagnosed with the disease at a young age, and had spent many years managing the disease and the painful benign tumors which would grow on the bones of his legs. Beginning in 2005, Mr. B had a total of four surgeries including a reconstruction of his right ankle, as a result of this painful disease. HMO had taken its toll on Mr. B’s entire body. Simple tasks became difficult. He would experience difficulty sitting and standing for any period of time, lifting and carrying anything weighing more than several pounds and even using a computer. His wife, a registered nurse, would spend evenings after work massaging his entire body in order to alleviate some of his pain.
Metlife’s In-House Nurse Consultant Determines That Yamaha Manager Has No Disability
After many years of enduring the pain caused by his genetic disease, Mr. B came to terms with the fact that he was no longer able to effectively perform his job duties as a manager for Yamaha, and would be forced to filed a disability claim under his employer’s long-term disability plan.
Upon receiving Mr. B’s claim, MetLife initiated its review, which included a medical records review by an in-house nurse consultant. MetLife’s nurse consultant was obviously not a licensed physician, and would not be a licensed medical professional with whom a patient diagnosed with HMO would seek medical treatment. In fact, a person diagnosed with HMO would treat with either an orthopedic specialist or a physician specialized in treating genetic bone disorders. MetLife’s nurse consultant was not a physician, much less an orthopedic specialist or bone tumor specialist. Despite her lack of expertise and experience with HMO, MetLife’s nurse consultant determined, without any basis, that the “medical records did not substantiate Mr. B’s restrictions and limitations.”
Mr. B Hires Disability Attorneys Dell & Schaefer To Appeal Metlife’s Wrongful Disability Claim Denial
Not knowing where else to turn, Mr. B searched the internet trying to find answers, and someone to help him correct this situation. It was simply incomprehensible how MetLife could take the opinion of a nurse, whom had never so much as seen a picture of him or intensely studied his medical condition, over the carefully considered opinions of his doctors – specialists in treating diseases of the bones.
Mr. B finally contacted Dell & Schaefer, and spoke with Disability Attorney Cesar Gavidia. Attorney Gavidia accepted Mr. B’s case and determined that, since Mr. B’s long-term disability plan was sponsored by his employer, and therefore governed by ERISA, it would be necessary to file an administrative appeal with MetLife before filing any legal action in court.
After gathering medical records and the administrative record from MetLife, Mr. Gavidia conferred with Mr. B’s treating physicians, obtained letters of support from Mr. B’s family members, friends and co-workers; and obtained all the evidence necessary to draft Mr. B’s ERISA appeal and ensure a solid administrative record.
Metlife Overturns Its Prior Claim Denial Following Submission Of Erisa Administrative Appeal
Following receipt of Mr. B’s appeal, MetLife’s administrative appeal unit sought the consult of an in-house physician consultant. After reviewing Mr. B’s appeal, which consisted of all of Mr. B’s medical records; eye-witness testimony of Mr. B’s physical limitations; and medical evidence supporting the claim from all of Mr. B’s treating physicians, MetLife’s in-house physician consultant concluded that the medical information submitted in connection with Mr. B’s appeal would support physical limitations, and that Mr. B was indeed disabled pursuant to the definition of disability in the policy. Following the physician consultant review, MetLife overturned Mr. B’s claim denial, and approved his claim for disability benefits.
The Importance Of A Properly Prepared ERISA Disability Appeal
Very often disability insurance companies will deny claims for lack of objective medical evidence of a disability. In Mr. B’s case, there certainly was not a lack objective medical evidence of a disability. On the contrary, there was a great deal of both objective and subjective evidence of a disability, and such medical evidence of a disability always existed. However, MetLife simply refused to acknowledge and properly evaluate it. Had the evidence establishing and supporting Mr. B’s disability not been presented through a properly prepared appeal, there is a likelihood that MetLife would have continued denying Mr. B’s disability claim, and Mr. B would have likely been forced to file a second appeal or perhaps been forced to file a civil action against MetLife in federal court to recover his benefits. Instead, Attorney Gavidia and Dell & Schaefer will continue to manage Mr. B’s long-term disability claim ensuring that Mr. B’s monthly disability benefits are paid timely and without interruption.
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