In the case of Karen N. v. Metropolitan Life Insurance Company et. al, the United States District Court of New York, after hearing arguments from both sides regarding MetLife’s Motion to Dismiss the case, denied the motion in its entirety and directs the parties to appear for a status conference to determine how and when the case will proceed. And, while the Court did deny the insurer’s motion, that doesn’t mean that Karen N. will receive a favorable outcome in her lawsuit to receive her disability benefits. It does mean that the Court believes that the case deserves to be heard and ruled upon once all facts have been established.
Karen N. And Her Disability Attorney File A Lawsuit against MetLife Insurance
In February 2007, Karen N. applied to MetLife for her short term disability benefits pursuant to her ERISA insurance plan after contracting Lyme Disease as a result of a tick bite. MetLife approved her for lyme disease disability benefits in March 2007, but in July 2007, the insurer terminated Karen N.’s short term disability benefits and then upheld that decision when Karen N. appealed. Then in May 2009, Karen N. applied for long term disability benefits without any response from MetLife. Consequently, in August 2009, Karen N. filed a lawsuit against the insurance company in an attempt to get MetLife to respond and award her disability benefits. MetLife, stating that Karen N.’s claim was untimely in that she did not receive the prerequisite twenty-six weeks of short term disability required to apply and receive long term disability benefits, filed a Motion to Dismiss Karen N.’s lawsuit. Karen N. alleged that the “condition precedent to receipt of LTD benefits did not actually exist in the relevant documents,” and thus, the untimely claim isn’t relevant to her lawsuit.
Karen N.’s Disabling Condition
Employed by MetLife as a Business Systems Analyst in the insurer’s Information Technology department, Karen N. was bitten by a tick on January 6, 2007, and subsequently developed Lye Disease symptoms, forcing her to discontinue working at MetLife on February 6, 2007. MetLife initially provided Karen N. with short term disability benefits, but terminated those same benefits in July of 2007, alleging that “Karen N. had not submitted sufficient documentary medical proof” that her claimed Lyme Disease prevented her from performing her job. She was informed she could appeal this decision internally under ERISA. No time limitation for filing the appeal was noted.
Karen N. did appeal the termination of her short term disability (STD) benefits and provided material documenting her symptoms of “chills, sweats, … fatigue, joint pains, stiffness, muscle twitching, burning pains/neuralgia and electrical sensations … lightheadedness and poor balance, … cognitive problems including brain fog, confusion difficulty thinking, difficulty with concentrating and reading, and poor memory, and an excessive … need for sleep,” all consistent with a diagnosis of Lyme Disease as well as Fibromyalgia. Her doctor documented that Karen N. is totally disabled and incapable of “returning to her previous job.”
Karen N.’s Doctor and MetLife’s Doctor Disagree About Karen N.’s Ability to Work
MetLife’s independent physician consultant did not agree with Karen N.’s doctor’s assessment, opining that Karen N. should be able to work with no restrictions. Consequently, MetLife upheld its earlier denial of disability benefits to Karen N. Karen N. and her New York disability attorney alleged that MetLife terminated her short term benefits in an effort to make sure Karen N. did not receive her anticipated long term disability benefits. She was told on numerous occasions that she could not apply for the long term disability benefits until she had received all of her short term disability payments. Karen N. did receive four months of short term disability benefits, and after the four months, she applied for her long term disability benefits. With no response from the insurer, Karen N. had little choice but to file a lawsuit against MetLife and let the Court decide her financial future.
ERISA Regulations and Time Limitations for Filing a Disability Claim
ERISA requires that insurer’s provide claimants with documentation or notice if time limitations are a factor in filing claims. In Karen N.’s case, her plan did not specify a time limitation nor did the letter she received informing her of the termination of her short term disability benefits supply that time limit information. And ERISA doesn’t create limitation periods but leaves that up to plan administrators. Consequently, if any limitations exist, they should be clearly stated so that claimants know what to do when filing disability claims. After reviewing similar issues through case law, Supreme Court decisions, and statutory requirements, the District Court of New York determined that Met Life’s argument supporting a Dismissal of Karen N.’s complaint outright had no merit.
In its memorandum about this case, the Court stated that MetLife violated ERISA regulations in claiming Karen N. did not timely file her complaint, and decided that Karen N.’s claim for long term disability benefits should proceed. Stating that MetLife “cannot rest on their allegedly wrongful denial of STD benefits to preclude Karen N. from challenging their failure to consider her LTD benefits claim and that the language allegedly creating the condition precedent is ambiguous,” the Court gave Karen N. permission to not only pursue her long term disability benefits from the insurer, but the means for suing the insurer should they deny those benefits.