In cases such as Lyme’s Disease, and the wider gamut of chronic pain conditions such as Fibromyalgia or RSD and chronic fatigue conditions, the symptoms reported are often subjective in nature. Meaning there is no test to pinpoint the amount of pain a person is experiencing or how fatigued they feel. Despite the fact there is no objective test to measure levels of pain or fatigue, the insurance companies, knowing full well this fact, demand objective proof of the subjective.
We have reviewed thousands of denial letters from every major insurance company demanding the very same. And, as in the Metlife disability case I will discuss below, the insurance companies are seldom forthcoming as to what the exact information required is.
A Court Victory for A Claimant Suffering With Lyme Disease
A Federal Court in the Southern District of New York has recently held that MetLife wrongfully terminated disability benefits to their own Metlife employee suffering from Lyme’s disease. In doing so, the Court ordered MetLife to immediately reinstate the plaintiff’s claim for Short Term Disability benefits, pay all back benefits owed for Short Term Disability and to begin a review of the plaintiff’s entitlement to long term disability benefits. The Court held MetLife abused its discretion by:
1) Rendering a determination that the Plaintiff did not provide substantial evidence to support her disability.
2) Failing to advise the Plaintiff of the information required to support her claim for Short Term Disability Benefits.
The plaintiff, Ms. N, was a former employee of Metropolitan Life Insurance Company (MetLife) from October 2004 to February 2007 and, as such, was covered under MetLife’s group short and long term disability plans. In January of 2007, after she was bitten by a tick, her primary care physician placed her on antibiotics as a preemptive measure even though there had been no formal diagnosis of any potential infection, including Lyme’s Disease, at that point. Shortly after being bit by the tick she began to report symptoms common to Lyme’s disease: joint pain, stiffness, muscle burning, balance problems, fatigue and cognitive difficulties related to attention, concentration and memory. The symptoms were severe enough to require a short hospitalization.
Application for Short Term Disability Benefits
Unable to physically return to work, Ms. N applied for short term disability benefits in February 2007. She treated with multiple doctors and had various tests performed to rule out any other conditions that might be the cause of her symptoms. MetLife initially approved her claim based on “chronic fatigue” and “severe weakness” and notified her that she was to provide specific medical information that demonstrated she continued to be disabled. It should be noted that MetLife never advised her as to what exactly that information was. MetLife ultimately paid 4 months of benefits out of a total of 26 possible weeks. In June of 2007, MetLife terminated her claim stating, “We have previously notified you of the information required for your disability benefit. Since that has not been received, your claim is being closed. . . .” The Court noted that the denial letter from MetLife made no mention of what information was not provided and made no mention of what would be required to constitute evidence of functional impairment.
Short Term Disability Administrative Appeal
Throughout the four months MetLife issued benefits, Ms. N submitted numerous medical records and notes from her treatment providers, all of which supported her inability to work in her former capacity due to the disabling symptoms of her Lyme’s Disease. During the administrative appeal process, she provided additional medical records and letters from her doctors and experts in Lyme Disease. Following receipt of her appeal, MetLife referred her entire file for an Independent Medical Record Peer Review. MetLife never had her physically examined by any doctor. Following the review, the hired doctor agreed that she suffered from Lyme’s Disease but that there were no objective findings in the records that would necessitate work restrictions. Based upon the review of the Peer Review doctor, MetLife upheld its denial of Ms. N’s claim.
Metlife Long Term Disability Claim
Following the denial of her appeal for short term disability benefits, she requested claim forms to file a claim for Long Term Disability benefits. MetLife informed her that they would not consider a claim for Long Term Disability benefits as she had not been deemed disabled for the maximum duration of short term disability benefits. Regardless of MetLife’s position, they forwarded her an application packet, which she ultimately submitted. The Court notes that MetLife neither acknowledged receipt of nor responded to the application in any way.
Metlife Disability Lawsuit
Ms. N eventually brought a civil action under ERISA to recover the remainder of her unpaid short term disability benefits and collect long term disability benefits. This claim was not handled by our law firm. Based on the claim history and Ms. N’s extensive medical history, the Judge determined that MetLife’s decision to terminate her claim for short term disability benefits and deny her administrative appeal were unreasonable. In turn, the Court ordered her short term disability claim be reinstated and a review of her long term disability claim be commenced. The Court deemed that MetLife’s actions were arbitrary and capricious on two grounds:
1) MetLife’s determination that Ms. N did not provide substantial evidence to support her disability
The Court identifies that MetLife did not deny her claim as a result of a dispute of diagnosis, rather because the information did not demonstrate she was unable to perform the essential duties of her occupation. This is a very common argument made by insurance carriers. With this as a backdrop, the Court analyzed the medical information in the administrative record and noted that even a cursory reading of the records compelled the conclusion that substantial evidence of impairment existed in the record. The Judge noted that all of the record evidence indicated that Ms. N was disabled and that there was no evidence that she was not. The Court also made specific mention that the Peer Review doctor relied on by MetLife never actually examined or met Ms. N.
2) MetLife’s failed to advise Ms. N of the information required to support her claim for Short Term Disability Benefits
As noted above, MetLife never advised Ms. N as to what evidence MetLife required to support her claim. Despite the numerous letters and statements from her doctors as to her inability to perform her work duties, MetLife continued to ignore this information and assert that there remained no evidence to support the restrictions and limitations placed on her by her doctors. The Court cited to ERISA regulations and requirements to provide a claimant with a “description of any additional material or information necessary for the claimant to perfect the claim“ and that it should be written in, “a manner calculated to be understood by the average plan participant.“ The Court determined that MetLife failed to provide Ms. N with any description or explanation of the exact evidence it was seeking.
The End Result
Ms. N finally won the remainder of her Short Term Disability benefits. However, the Court did not grant her claim for Long Term Disability Benefits, but instead remanded it back to MetLife to make a determination as to her entitlement to same.
Our Legal Commentary
Insurance companies frequently deny claims on the grounds that there is “no objective evidence to support physical restrictions and limitations.” As the Court in this case noted, MetLife did not dispute the diagnosis, rather it argued that the medical evidence did not support work restrictions. It is a fine subtlety that is often conveyed in the concept of “Diagnosis does not equal Disability.” As with all disability claims there has to be a connection between the medical condition and the inability to work. It is very difficult for an insurance company to necessarily dispute a medical diagnosis from a doctor. They are smart enough to know this fact so they instead seemingly approach their claim review by not reviewing the information which is contained in one’s medical records, but, rather the information that is not.
From a practical standpoint it should be noted that Ms. N’s claim for short term disability benefits was terminated in June 2007. This Court decision was rendered in December 2012, five and a half years after her ordeal began. Even more important to note is that the Judge only ordered MetLife to pay the remainder of the 26 weeks of short term disability benefits not paid, or approximately two and a half months. As of the date of this article it is unclear as to the status of her claim for Long Term Disability benefits and if the case law has taught us anything, it’s that an insurance company does not have an affirmative duty to approve benefits on remand just because a Court orders a review or sided with a Plaintiff. MetLife could easily deny Ms. N’s claim for long term disability benefits and she would have to start the whole process over again.
This case creates a highly beneficial body of law to be argued against insurance companies who deny claims for the above mentioned reasons. However, it should be noted that every case, every Court and every judge is different. As much as ERISA is supposed to be a unified body of law the administration of the law is anything but.
Disability Attorneys Dell and Schaefer always offer a free phone consultation on all disability insurance claims.
You can read more about the Lyme Disease Disability here.