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Metlife Overturns Denial on Appeal by Dell & Schaefer

Attorney Victor PeñaAuthor: Attorney Victor Peña

Mr. W was working as a Quality Assurance Engineer for a major technology company when he was forced to stop working at the age of 52. He had been suffering from severe heart disease and co-morbid complications. He also suffered a heart attack and had a progressively worsening diabetic foot ulcer which required him to use a knee scooter to ambulate.

After filing a claim for disability benefits under his employer sponsored disability plan, MetLife approved his claim and paid benefits effective October 2015 for his inability to perform his occupation due to his chronic foot ulcers.

Initial claim approval and subsequent denial

MetLife paid benefits to Mr. W for two years before sending him a letter in October 2017 notifying him that his benefits would be ending. The denial letter included statements from Mr. W that his condition had improved in that he was “not using a knee scooter 100% of the time.” The denial also relied on an Attending Physician statement (APS) from a treating physician indicating that Mr. W was released to return to work with restrictions.

Mr. W contacts our firm

Almost immediately after receiving the denial letter, Mr. W contacted our law firm and spoke with Attorney Victor Peña. Attorney Peña reviewed the denial letter and it became clear that it was a claim that had been damaged by the improper completion of claim forms by the treating physician as well as the claimant.

The denial was most likely the result of misleading questions on confusing claim forms which claimants and their doctors are required to complete for the claimant to continue receiving disability benefits. As one of the most common reasons for a disability denial, we see frequent denials where the insurance carrier relied on statements from claim forms that do not accurately reflect the claimant’s condition. Statements describing an “improvement” or “normal” or “stable” conditions are often mischaracterized by the insurance company and used as a basis to deny a claim.

Such was the case with Mr. W when he received his denial letter from MetLife. The appeal had to undo the damage that had been done and which MetLife relied on to deny the claim. Attorney Peña and his team focused on gathering evidence that proved that Mr. W’s condition had not improved. In the process of preparing the appeal it also became apparent that MetLife had placed too much weight on and focused almost primarily on Mr. W’s foot condition as the sole cause of his ongoing impairment. It also became clear that MetLife had misconstrued the attending physician’s statement which it declared supported a denial of benefits.

Appeal by Dell & Schaefer

To paint an accurate picture of Mr. W’s actual functional abilities, Attorney Peña and his team elicited more detailed and more specific responses from the treating physician most familiar with Mr. W’s condition. The doctor’s responses supported that Mr. W was unable to perform even a sedentary occupation on a full-time basis. In total, the appeal consisted of 3,432 pages of arguments and medical exhibits supporting Mr. W’s claim.

MetLife took less than 45 days to review the appeal before overturning its adverse decision and issued a letter to our office that Mr. W’s claim would be reinstated.

This case is a perfect example of a claimant who deserved to be on claim but was a victim to the misleading and confusing questionnaires provided by insurance companies. Claimants and their treating doctors often struggle to complete these forms and mistakes are easy to make when you don’t have experience filling out the forms. Fortunately Mr. W contacted our office in time and we were able to get him back on claim.

Mr. W continues to be represented by our office and continues to receive disability benefits.

If you have a similar claim or you are struggling to complete the forms required by your insurance company please contact one of your attorneys to discuss your options. It is important to get an attorney involved before it’s too late.