US court of appeals upholds denial of disability benefits by MetLife

Another case appeared in the U.S. Court of Appeals that highlights the importance of exhausting all the administrative options available before taking a case to court. Additionally, this case demonstrates the importance of a treating physician responding to all requests from a disability insurance company.

What happened here? And what can you learn from this case that could help you win your claim for disability insurance benefits?

First, we will look at the history of the case. Then we will look at the law as the court interpreted it.

Luis Medina was a maintenance technician at the Puerto Rican Abbott Laboratories, Inc. facilities. He participated in the disability insurance plan administered by Metropolitan Life Insurance Co. (MetLife) for his employer. When he was diagnosed with obstructive sleep apnea and high blood pressure in June of 2006, he quit working and applied for short-term disability benefits.

Along with his application, he provided a diagnostic report prepared by his treating physician. On August 1st, MetLife granted Medina short-term disability benefits for a limited period, but the insurance company made it clear that additional documentation confirming that Medina truly qualified for disability payments would be required.

Medina’s doctor submitted a second evaluation on August 21st. It contained additional diagnoses but minimal test results to verify the how these diagnoses would impact Medina’s ability to work. MetLife made several attempts over the next two months to reach Medina and his doctor. While they did make contact with Medina, his attending physician responded to neither the letters, faxes nor phone calls from MetLife. Medina said he would speak with his doctor.

Finally, on November 13, 2006, MetLife received a progress report from Medina’s doctor covering the time from June 4 through August 16. It was based on the quality of this progress report that MetLife issued a letter in December terminating Medina’s short-term disability benefits. In brief, here is what they indicated was missing:

Medina appealed MetLife’s decision in late December 2006. MetLife agreed to submit the claim to an independent medical consultant. On January 7, 2007, Medina forwarded additional progress reports from his doctor and more details were supplied about the symptoms Medina was experiencing and the diagnoses and treatments being used. With this information added to the file, MetLife referred the entire claim file as agreed for independent review.

On January 31, 2007 the review came back. Met Life’s doctor found that there were insufficient clinical findings and too little data to support Medina’s claim. The physician just couldn’t find enough evidence to support Medina’s inability to return to the duties of his position. Two days later, on February 2, MetLife faxed a copy of the report to Medina’s doctor asking him to provide evidence if he disagreed with the findings in order to disprove them. The doctor claimed he didn’t receive it.

Meanwhile MetLife also called Medina repeatedly, asking him to relay the message to his doctor that they were trying to reach him. Medina kept telling MetLife that he had relayed the message and that his doctor was getting upset, because he didn’t have anything more to send.

Mid-March rolled around. MetLife was still waiting on a response from Medina’s doctor. On March 21, 2007, the insurer finalized its review of the file and concluded that there was no evidence that supported reversing the denial of benefits. Medina was notified of the decision and that he had exhausted all available administrative remedies.

On April 12, Medina wrote MetLife requesting all relevant documents on which it had relied in reaching its decision. He specifically asked for a copy of the fax sent to his doctor, along with the confirmation page demonstrating that it had been transmitted successfully. Within a week, he had the entire file minus the transmittal sheet.

Medina sued MetLife for denial of short-term and long-term disability benefits in Federal District Court for the District of Puerto Rico, filing a motion for judgment on the administrative record. District court reviewed the administrative record and found that MetLife had not abused its discretion in denying Medina’s claim. As a result the court denied Medina’s motion and granted summary judgment to MetLife. Medina appealed.

The U.S. Court of Appeals conducted a de novo, or fresh, review of Medina’s case. The Court looked for evidence that MetLife had been arbitrary or capricious in its decision. They found that MetLife’s decision had been reasoned and supported by the evidence (or in this case lack of it).

Medina claimed that the evaluation by the independent consultant was based on false information, as indicated by the description of Medina’s job duties being “medium work.” This point had not been raised during the month and a half that MetLife had tried to reach Medina’s doctor, or during the claim in district court. The Appeals Court would not consider the argument.

Medina claimed that MetLife had failed to give sufficient weight to his attending physician’s evaluations. The Appeals Court disallowed this argument as well, stating that case law does not require the administrator to give more weight to the attending physician’s evaluations. Especially in the presence of contradictory evidence, the administrator is entitled to exercise its discretion.

The court also found that the independent doctor’s review offered substantive reasons for offering a contrasting view. He cited the many diagnostic tests that were not present in the record. He also pointed out that it is very rare for sleep apnea to cause impairment.

Finally, Medina claimed that MetLife was required to wait until they received his doctor’s feedback on the independent report before making a final decision. MetLife claimed to have sent the fax, which was present in the administrative record. Medina claims it was never received and the very fact that it was sent proved that it was deemed necessary by MetLife. Medina claimed a decision made without that information was inherently arbitrary and capricious.

The Court didn’t buy the argument. The record indicated that Medina had ample notice that MetLife was seeking more detailed information and was actively trying to contact his physician. The Court saw no reason why MetLife should be held hostage by a physician who did not reply to their communications, especially when the law didn’t even require them to give special weight to his findings. The fact that his doctor did not supply comment or additional information, validated Medina’s claim that the doctor was upset and had nothing further to say. When the fact that Medina had the fax in hand shortly after the denial of benefits was considered, failure to present supporting evidence to refute the report didn’t assist Medina’s argument either.

Medina had also included a claim for denial of long-term disability insurance. District court required him to present proof of his application. He had not done so, and at the time of appeal, still could not produce anything but circumstantial proof of having done so. The court ruled that the district court was correct in finding that Medina had failed to exhaust his administrative remedies with regard to his long term disability claim.

Medina’s case didn’t go well for him for two reasons. He failed to provide the information needed to demonstrate the nature and severity of his disability. And he failed to apply for long-term disability before he filed a lawsuit. Unfortunately, Medina did not have a cooperative physician, and therefore he never stood a chance of winning his claim for disability benefits.

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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.

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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
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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.

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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.

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