MetLife Pre-Existing Condition Disability Benefit Denial for Back Injury Reversed

Does a Pre-Existing Back Injury to L4-5 Preclude Benefits for an Injury to L2-3?

In Karl Meche v. Metropolitan Life Insurance Co., (MetLife), Plaintiff had worked for about six months as an account manager for Air Liquide USA LLC, when he injured his back at work. On July 20, 2016, he was moving a cylinder for his employer when he heard his “back pop.” He reported the injury to his medical providers.

After receiving short-term disability (STD) benefits from MetLife, Plaintiff’s claim for long-term disability (LTD) benefits was denied. MetLife decided that since Plaintiff had a previous diagnosis of degenerative disc disease (DDD) which resulted in a spinal fusion on L4-5, his injury at L2-3 was due to a pre-existing condition.

On administrative appeal, MetLife again denied Plaintiff’s claim for LTD benefits for the same reason: he had a pre-existing condition. After exhausting his administrative remedies, Plaintiff filed this ERISA lawsuit in the United States District Court for the Eastern District of Louisiana.

Plaintiff presented two main questions to the District Court: 1) Did the policy preclude payment in general for a disability that “results” from a pre-existing condition; and 2) If so, did Plaintiff’s disability result from a pre-existing condition.

After careful analysis of the policy terms and Plaintiff’s medical records, the Court decided in favor of Plaintiff, holding that although the pre-existing condition clause in the policy was valid, his disability was not the result of a pre-existing condition. Therefore, the Court ordered MetLife to pay Plaintiff past and future LTD benefits for the back injury he suffered at work.

The Pre-Existing Conditions Clause in the Policy is Valid

MetLife’s policy identified several instances when an employee would be deemed to have a pre-existing condition. For example, if the employee had received treatment or taken medication for the condition in the 12 months prior to the date the policy went into effect, that would be considered a pre-existing condition. MetLife would pay benefits for a pre-existing condition if the employee became disabled after working for the employer for an entire year after the insurance became effective, or if the employee had not received any treatment for the condition or taken any medication for it for three months following the date the insurance began.

Plaintiff argued this clause should be invalid since it identified when payments would be made for a pre-existing condition but did not articulate when benefits would not be paid. The Court disagreed with Plaintiff and found that since the clause was written “in an ordinary and popular sense as would a person of average intelligence and experience” understand it, it was valid. The Court concluded “that the clause at issue validly permits the denial of benefits based on a pre-existing condition.”

Plaintiff’s Disability Was Not the Result of a Pre-Existing Condition

MetLife did not dispute the fact that Plaintiff suffered a work-related injury. It just argued that since Plaintiff had pre-existing DDD, he was precluded from collecting long term disability (LTD) benefits. An analysis of Plaintiff’s medical record showed that prior to his work injury, Plaintiff had undergone surgeries for DDD at Level L4-5.

Medical testing documented that after his injury, Plaintiff suffered problems related to levels L2-3. This was a new part of his back. There was no evidence in his medical records that indicated Plaintiff had ever had any issues at L2-3 prior to the injury.

Plaintiff’s pain changed after the accident. Before the injury, his pain was localized to his lower spine, around his belt-line, areas known to cause pain due to an L4-5 injury.  Plus, prior to the accident, his pain was under control with medication, and he was able to work. In fact, prior to the injury at Air Liquide, he worked as an industrial engineer for 20 years, and was able to walk, play baseball and engage in “an active lifestyle.”

After the injury, that affected L2-3, Plaintiff suffered “with intense, uncontrollable pain.” He lost mobility. He increased his use of painkillers. He could not “tolerate sitting or standing for significant amounts of time.” He could only drive for limited periods of time and on many days, he was unable to get out of bed.

The Court noted, “In sum, therefore, the changes in location, magnitude, and effect of [Plaintiff’s] pain suggest that the pain does not arise from a preexisting condition. And overall, the occurrence of a workplace injury, followed by new anatomical findings, tied to different symptoms, all provide evidence that [Plaintiff’s] disability does not result from a pre-existing condition.”

In addition, MetLife’s consultant used the wrong standard in recommending denying benefits. She stated that Plaintiff’s problems were “‘related’ to the pre-existing condition.” The policy requires the disability to “result” from the pre-existing condition. This phrase requires a “causal relationship between the pre-existing condition and the disability at issue, not mere association.” The Court found that MetLife did not meet its burden to show a causal relationship.

The Court held that “MetLife unlawfully denied [Plaintiff’s] long-term disability benefits. The Court therefore orders MetLife to pay [Plaintiff] past and future long-term disability benefits for his July 20, 2016, back injury.”

Contact Dell & Schaefer

This case was not handled by our office, but we believe it can be instructive to those struggling with an insurance company that is denying them benefits based on a pre-existing condition. For questions about this case, or any question about your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

There is one comment so far

  • my employer denied work accommodations from 3 doctors forcing me to file MCFL similar to FMLA. I filed with MetLife who denied my STD – existing condition. I had anxiety related to an adverse reaction to Valium, whereas here my employer and Pandemic was causing my anxiety.

    Lisa May 3, 2022  #1

Leave a comment or ask us a question

Questions About Hiring Us

Do you help MetLife claimants nationwide?

We represent MetLife clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a MetLife disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from MetLife. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by MetLife.

How do you help MetLife claimants?

Our lawyers help individuals that have either purchased a MetLife long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with MetLife:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
  • Daily Handling & Management of Your Disability Claim
  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Demetric W. (Maryland)

Before I called Dell & Schaefer I called several law firms in my area and to my disappointment, I was unable to find a local attorney who I felt could really help me settle my long-term disability claim. I was at the end of my rope and I did not want to deal with my insurance carrier anymore because of the tactics they used throughout the years after I became sick. I was just about to give up until I discovered a Dell & Schaefer video on YouTube. I was amazed at the information presented because I felt as if they were speaking directly to me. As a result, I contacted the law firm and was able to speak to an attorney the same day.

I would like to take this opportunity to thank Mr. Stephen Jessup for your professionalism and prompt way of handling my case. It is very hard to find a law firm that will educate clients on all of the logistics that lead up to the final settlement offer. I will recommend your services to anyone who has legal insurance needs in the future. I’m still in shock about my settlement. Your services have far exceeded my expectations in every way. Again, thank you for all you have done for me.

I would also like to thank Ms. Sonia R. Nogueira for your constant reassurance and for always making me feel like I could call you any time and as many times as necessary with questions. Thank you for your kindness.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us