The claimant is a 44 year old female who worked as a Campaign Delivery Director for American Express. She was forced to go out of work on disability on April 7, 2014, after being psychiatrically hospitalized due to the onset of severe symptoms of depression and anxiety. In addition to her behavioral health symptoms, she also suffers from chronic diffuse pain and had been diagnosed with Ehlers-Danlos syndrome (EDS), autoimmune syndrome, and fibromyalgia. She applied for Long Term Disability insurance benefits under the terms of her policy with MetLife. MetLife approved her claim as of her date of disability of April 7, 2014, and in a letter dated November 17, 2014 informed her that her claim for LTD benefits was payable effective October 5, 2014. MetLife further advised that:
Therefore, after paying benefits for a period of 24 months, MetLife arbitrarily terminated her LTD benefits effective October 4, 2016, on the basis that she met the maximum benefit duration for a limited condition (mental illness) under the terms of the Policy.
MetLife blatantly ignored all physical claims and automatically terminated benefits after 24 months
Upon further review of MetLife’s claim file, it is evident that its reviews, assessments, and conclusion were not only flawed but clearly tailored to meet MetLife’s goal of averting further liability under the LTD policy. MetLife ignored the medical evidence of significant physical impairments due to her “non-limited” conditions of Ehlers-Danlos syndrome, autoimmune syndrome, and fibromyalgia which supported ongoing restrictions and limitations that would have precluded her ability to perform the material duties of her job or any gainful work beyond October 4, 2016. Furthermore, given the ambiguous nature of the LTD Policy’s mental health limitation, MetLife’s application was not appropriate as it did not afford consideration to the causative nature of her disability.
MetLife determination gave no deference to the impact non-limited conditions have on overall functionality
The medical evidence demonstrated that the claimant had a long-standing history of severe diffuse joint pain. She was initially diagnosed with an auto immune syndrome and Ehlers-Danlos syndrome (EDS) which is a hereditary connective tissue disorder characterized by joint hypermobility, widespread musculoskeletal pain and tissue fragility. She was later diagnosed with fibromyalgia as well.
She commenced treatment with acupuncture in early January of 2015, subsequent to her disability effective date, due to progressively worsening symptoms of joint pain particularly in her neck, shoulders, back, hands, knees, and thighs. It was noted her condition worsened with prolonged sitting, extended work hours, stress, anxiety, sickness and weather change. The claimant was seen on a weekly basis for acupuncture treatment to reduce the severity of her pain but received minimal to no improvement.
In February of 2015, the claimant commenced care with a rheumatologist, Dr. Levine. The initial evaluation on February 25, 2015 confirmed that she was hyper- extensible on examination and that her pain was related to EDS. However, during a subsequent visit on July 21, 2015, it was noted that she continued to have chronic pain with aches in her joints and at times her right hip intermittently popped out. Laboratory testing performed revealed ANA 2+ as well as low complements. In addition, Dr. Levine confirmed numerous tender points on examination. These findings, as well as her associated depression, trouble sleeping, and sense of feeling better after cardiovascular exercise were noted to be consistent with a diagnosis of Fibromyalgia. Dr. Levine further reiterated that her pain was also attributable to EDS.
In a Physician Statement from dated September 28, 2015, Dr. Levine opined, based on her physical examination, she was only able to sit 2-4 hours total and intermittently in an 8 – hour workday due to her physical non-limited conditions. She further noted limitations in fine motor coordination due to “finger pain & swelling”. Dr. Levine confirmed that she had not yet attained maximum medical improvement and noted that she required frequent breaks and rest due to body pain and fatigue.
MetLife admits claimant is disabled due to a physical condition and overturns its decision after appeal
MetLife’s actions to include selectively ignoring the medical evidence of physical disability and failure to perform a complete and thorough review of all of the claimant’s disabling conditions were arbitrary and capricious and demonstrated an abuse of any purported discretion it may have under the LTD Policy. Clearly the medical evidence demonstrated that her disability extended far beyond her mental diagnoses. As confirmed in Dr. Levine’s follow up office note dated January 19. 2017:
She continues to struggle with body pain and fatigue. She has some joint pain, particularly in hips bilaterally, as well as pain in the neck, shoulders, and upper back. She fatigues easily, both physically and mentally. It is evident based on the aforementioned that even in absence of mental diagnosis; she would continue to be disabled in accordance with the terms of her LTD policy due to her chronic pain stemming from her rheumatological conditions.
MetLife erred in its decision to deny benefits based solely on the policy’s mental health limitation. After reviewing an extensive appeal submitted by attorney Rachel Alters, Metlife overturned its determination to terminate benefits and reinstated the claimant’s LTD benefits paying all back benefits owed. The claimant remains on claim for her inability to work in any gainful occupation due to fibromyalgia and EDS.
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