Programmer Denied LTD Benefits by MetLife Upheld by Court

In the case of Robert Gordon v. Metropolitan Life Insurance Company (MetLife), Plaintiff was a Senior Staff Systems Programmer with Borland Software Corporation from 1989 until he was fired on May 1, 2002. He suffered from a multitude of psychological and physical conditions including depression, anxiety, and post-traumatic stress disorder (PTSD). He claimed these problems were all due to harassment and threats he received from his immediate supervisor. He also suffered from spinal, knee, and shoulder injuries.

On April 19, 2002, his physician ordered him to take one week off work. Plaintiff did not return to work until May 1, 2002. On that same day, he was fired due to performance issues.

Summary of the Underlying Facts

On October 22, 2009, several years after he was fired from his job at Borland, Plaintiff filed a claim for long term disability (LTD) benefits dating back to April 19, 2002. He listed a myriad of problems along with a note from a treating physician which stated Plaintiff had “disabling back & neck pain for degenerative disc disease, chronic migraine headaches and failed knee and shoulder surgery since February of 2002.”

The claim was denied, so Plaintiff requested an administrative appeal. On appeal, his claim was again denied. His disability insurancecarrier, MetLife informed him that he had coverage under its policy through May 1, 2002. But, the medical information provided did not support a finding of disability during the time he was eligible for coverage.

The ERISA lawsuit, which had been filed prematurely and stayed while MetLife considered the administrative appeal, proceeded and both parties filed Motions for Summary Judgment. The Court conducted de novo review and held in favor of MetLife, finding that Plaintiff did not prove by the preponderance of the evidence that he was disabled during the time he was covered by the MetLife policy.

Plaintiff Was Ineligible for Benefits Under the Terms of the Policy

According to the MetLife policy terms, in order to receive LTD benefits, Plaintiff must have met certain eligibility requirements prior to May 1, 2002, the date of his employment termination. He must have been disabled to a degree that he was unable work in his own occupation for any employer in the local economy. Specifically, the relevant clauses include:

Definition of disability. “Disabled” means that “due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis.” Appropriate Care means medical care that meets all the following:

·        It is received by a medical professional whose training and experience are suitable for treating the claimant’s disability.

·        It is necessary to meet the claimant’s basic health needs.

·        It is consistent in type, frequency, and duration of treatment.

·        It is consistent with the diagnosis.

·        Its purpose is to maximize claimant’s medical improvement.

In addition, the claimant’s loss of earnings “must be a direct result of [the claimant’s] sickness…”

Income loss. The policy states: “During your Elimination Period and the next 60 month period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own occupation for any employer in your Local Economy.”

The United States District Court for the Northern District of California, San Jose Division, conducted de novo review of Plaintiff’s claim and analyzed in detail the reports of 12 physicians who had treated him over the course of several years. The Court also reviewed details of three physicians who conducted a review of the medical record on behalf of MetLife.

The Court determined Plaintiff was not entitled to LTD benefits stating:

“Having conducted a de novo review, the Court finds that the Plan correctly determined that Plaintiff was not “Disabled” from performing his “own Occupation” prior to his May 1, 2002 termination date. Although the Administrative Record confirms Plaintiff suffered from multiple medical conditions prior to May 1, 2002, the medical records fail to establish (1) that Plaintiff was receiving care and treatment for any of those medical conditions on a continuing basis and (2) that during the Elimination Period and the next 60 month [sic] period Plaintiff was unable to earn more than 80% of his Earnings or Indexed Predictability Earnings at his Own Occupation for any employer in his Local Economy.”

For these reasons, the Court held that Plaintiff was not entitled to LTD benefits since he had not met his burden to prove that while he was covered by the Plan, which was prior to May 1, 2002, he was disabled within the meaning of the Plan.

This case was not handled by our office, but we feel it is instructive to those who may have a similar issue. If you have any questions about your disability claim, contact one of our attorneys at Dell & Schaefer for a free consultation.

Leave a comment or ask us a question

Questions About Hiring Us

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   *****

Perrin B, DDS

Dear Mr. Dell,
I was given your name as a referral for representation for the counsel and filing of a disability claim on my behalf. I understood that this would be a challenging effort and that it would be time consuming, frustrating and nearly impossible to do on my own. Our initial meeting was so reassuring that I hired you on the spot. The navigation of my office sale, the negotiations, the process of dealing with my illness and its symptoms and the entire ordeal seemed overwhelming at times. You and your staff were and remain amazing. Your conscientious and genuine concern were so reinforcing, your timely and efficient follow through was consistent with the service you promised and often exceeded my expectations.

I suppose I should add that my disability insurance carrier must have been equally impressed by your individual and team efforts as I was granted a full approval for my claim. There was no way that I could have achieved this without your excellent, ethical and efficient representation. I would also like to add that your assistant was a godsend. A sympathetic and caring soul, her attention to every detail and her patient attention to my needs during the process added greater confidence and support for my efforts.

Mr. Dell thank you again for making this process easier to navigate for me. Please feel free to give my contact information to anyone considering your services as I would be happy to serve as a permanent source of endorsement for you, your staff and your excellent performance on my behalf. Thanks again, you are a life saver!

***** 5 stars based on 202 reviews

Speak With An Attorney Now

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