Missouri Court denies MetLife’s motion to dismiss long-term disability claim for failure to exhaust administrative remedies

Donna Blake was an employee of Express Scripts, covered under both a long term disability plan and a short term disability plan, when she applied and was denied for short term disability coverage.  After internal appeals, Mrs. Blake brought her claim to the United States District Court, Missouri Eastern Division.  Upon the settlement of Mrs. Blake’s claim for short term disability, she claimed that she would be prevented from filing for long term benefits, because the denial of her short term disability claim, “prevented her from applying for LTD benefits from the LTD Plan, as she was required to satisfy the applicable period of STD before becoming eligible for LTD benefits.”

She claimed that she had exhausted all administrative remedies available to her when it came to filing for the long term disability because of the fact that she could not satisfy the applicable period of short term disability,  which is twenty-six weeks. Typically, employees are not allowed to apply for long term disability benefits until they’ve been on short term disability for more than twenty-six weeks.

Met Life asked for a dismissal of this claim because they say Mrs. Blake has not exhausted administrative remedies available under the plan.  They say her case is premature, because she never even said she applied for long term benefits.  They say that her claim that applying for long term benefits would have been futile is not necessarily true.  They say that she has asked for a long term benefits application but has not received one yet, and on the grounds that she has not even applied, the claim should be dismissed.

Mrs. Black maintains that because of the fact that she was not able to obtain short term benefits, technically, Met Life would have grounds to refuse long term benefits to her. Because long term benefits are scheduled to take over as soon as short term benefits run out (provided the proper records are shown and the individual is considered disabled) Mrs. Black wouldn’t normally even be considered for long term benefits.

Met Life stated that because Mrs. Black settled her claim of short term disability, she has “eliminated any previous obstacle to plaintiff’s application for LTD benefits.” Met Life promised to consider the medical documentation that Mrs. Black would submit in order to apply for long term benefits.  They claim they’ve given literature to Mrs. Black’s attorney regarding the long term benefit plan, and maintain their stance.

The court took a long look at the motion to dismiss from Met Life. Because what Mrs. Black is saying is correct,  that she would automatically be denied long term disability benefits that were set to kick in after the short term disability benefits because she was unable to receive the latter,  the court finds in her favor and refuses to dismiss the claim. Therefore, in a case where an individual may not have been on short term disability for the required time before applying for long term benefits, it does not mean that they cannot receive the long term benefits.

The reason in this case that the court found in favor of Mrs. Black pertains to the disability contract of Met Life.  The disability contract states that once the short term benefits have exhausted themselves, the long term benefits would begin paying so long as the individual submitted the appropriate proof of disability.  It does not state anywhere that an individual can apply for long term benefits if they have not exhausted short term benefits first.

Because of the court’s decision, Mrs. Black can apply for the long term disability benefits and with enough medical evidence, may be able to receive it.

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