Winning Isn't Easy: Long Term Disability ERISA Claims

Carrier Spotlight Series: What Disability Insurance Policyholders Insured Through MetLife Need To Know About Their Claims Denial Tactics

October 25, 2021 Nancy L. Cavey Season 2 Episode 36
Winning Isn't Easy: Long Term Disability ERISA Claims
Carrier Spotlight Series: What Disability Insurance Policyholders Insured Through MetLife Need To Know About Their Claims Denial Tactics
Show Notes Transcript

Nationwide Long Term Disability Attorney Nancy L. Cavey talks about the insurance carriers and the games and tricks they like to play with your disability policies! In this episode we feature  MetLife Disability Insurance  as the Carrier Spotlight!

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Nancy L. Cavey:

Hey, I'm Nancy Cavey national ERISA disability attorney and IDI disability attorney. Welcome to a Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer, this podcast isn't legal advice. The Florida bar association says, I've got to say this. So now I've said it. Nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games, the carriers play and what you need to know to get the disability benefits you deserve. So let's talk about MetLife today. Do you have a MetLife short-term or long-term disability insurance policy, or are you the beneficiary of an employer provided MetLife disability plan? If so today's podcast is for you, but if you're not insured by MetLife, you can still learn lessons from this podcast. I'm going to talk about three things today. First, what happens when your disability claim straddles two insurance companies? When your employer changes carriers, can MetLife demand that a policy holder with chronic headaches produce objective evidence of their disability. And last accord acknowledges that a cardiopulmonary exercise test, a CT pet test is the gold standard for measuring the functional capacity of a disability insurance policy holder with fibromyalgia and how the doctor's failure to explain the basis of the disability can doom your claim. So let's take a break before we get started.

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Nancy L. Cavey:

Welcome back to winning isn't easy. What happens when your disability claim straddles two insurance companies? When your employer changes carriers? Now it's not uncommon for employers to change disability carriers, but what happens if you become disabled during the period of time in which your carrier is being changed by your employer, which carrier Fannie will pay you benefits? What happens if both carriers deny the claim? What do you do now? This is a bit of a factually complex issue , uh , at a policy complex issue. So bear with me because facts matter. And the terms of the policy matter in this particular case, Mr. T faced this problem. When he became disabled due to tri genital neuralgia, and he had surgery, he worked for back then Dickinson and company BD , and they had a disability plan that was insured in 2016 by standard and in 2007 change to MetLife. He first went out on disability on November 9th, 2016, write that down. He was on short-term disability through December 22nd, 2016. Write that down. He returned to work as a product development engineer on December 23rd, 2016. So write that down. He then had a relapse that took him out again on January 12th, 2017. Now remember the carrier changed in 2017 . So write that down, Mr. T exhausted his short-term disability claim and then filed a long-term disability claim with standard. So guess what standard did standard said, oh no, we're not going to pay you any benefits because you weren't covered under that policy. Really? Hm . Not to be out done. Mr. T filed a claim with MetLife and they said nothing. They ignored him. So then he sued standard MetLife. And the plan now during litigation, he settled the standard claim and standards policy had a provision called the effects of recovery. This is an important term in a disability policy. So if you're facing this situation, you need to get out your policy. This provision said that no long-term disability benefits would be payable after benefits became payable to you under any other disability insurance plan under which you became insured during your period of temporary recovery. That's a lot of words, isn't it. Now, this is an interesting provision because many policies and plans have a provision that says, if you become disabled again, because of the same condition for which you are collecting benefits and you do so within a specified period of time, normally 60 to 90 days, you're entitled to your benefits. That's called a recurrent disability provision. However, in this case, the policy had a twist and the twist was that if there was a new policy under which you become insured during this period of time, this recurrent disability provision, there was no coverage. Now that's amazing. And you can see why you have to get out and review your own specific disability policy or plan because there no uniform policy or plan. As I said, this case is fact specific and policy specific. This case ultimately went to the fifth circuit in the case of Mr. Talamantes versus Metro MetLife. And it's a fifth circuit case that came out in June of 2021. Now the court rejected MetLife's argument, that standard was responsible for the payment of benefits because MetLife had argued that benefits were never payable under their policy and that he was only eligible for coverage. Okay. That's an interesting twist. Well, what are the policies say? The , the 2017 MetLife policy explained coverage took effect when an employee was covered under a prior plan, which was here and was actively at work on the day before the replacement date. Well remember I told you to write down dates. The court noted that the replacement date was January 1st, 2017 , and he worked through January 11th, 2017. So the court reasoned that MetLife's interpretation was dependent on the merits of each disability claim. And that the plan beneficiaries would never know if they had coverage or not, until they litigated the case. The court said, oh, no, no. The purpose of Arista , which governed this claim is to bring uniformity to the claims process and met life's interpretation, led to uncertainty. Now, the court also looked at the standard policy language. That language was clear that the benefit coverage had shifted from standard to MetLife based on the circumstances of this case and the language of the policies Mr. Talabani standard coverage ended when a new plan became effective. January 1st, 2007, he was actively at work and disabled on January 11th, 2017 . And he was covered under the MetLife policy. Now, in my opinion, this is a correct decision based on the facts and the policy. But I will tell you, it's not uncommon for disability carriers to point the finger at each other and say, you were not responsible. You are, I don't want you to let your disability carriers Rob you of your peace of mind. And you can see that this is a fact intensive policy intensive issue. If you have this type of situation, you need to consult with an experienced , there is a discipline attorney. Who's going to want the facts, the medical chronology, the return to work chronology and the terms of the policy. So they can try to figure out this interesting dilemma. Now I'm going to pause for a moment and take a break. But when we come back, I'm going to talk about whether the character and the man objective evidence in a migraine claim. So stay tuned. We'll go back to winning. Isn't easy. Can MetLife demand that a policy holder with chronic headaches produce objective evidence of their disability facts matter in a disability case that's particularly true. When the policy holder has a subjective medical conditions like chronic headaches, a chronic headache is considered subjective because there's no objective diagnostic testing or gold standard tests to determine whether in fact you have chronic headaches, many courts will acknowledge the chronic headaches and migraine pain is the type of medical condition that is difficult to diagnose through labs reports and imaging scans. Yet many disability carriers insist on objective evidence or evidence as a prerequisite for disability. Even when the disability policy in question doesn't even require objective evidence of proof , they make it up. And that's exactly what happened in the case of Hamid versus life , which is a Northern district California case. Now, Mr. Hamid was the enterprise retail sales manager of the bank of America. And he managed the mortgage department for eight boa branches and managed 10 to 15 employees. Unfortunately, he had had a migraine headache issues. As early as 2000. He had seen over a dozen different doctors for these problems. He had been seen by neurologist, allergists , rheumatologists , you name it, you've been seen by them. He underwent both conservative and invasive treatment, including multiple nasal surgeries and Botox injections. Unfortunately, none of that was successful. His medical records documented his chronic head and face pain, which was cooperated by family members and coworkers . He stopped working because of those frequent migraines, persistent pain and pressure in his face and head. He also obviously would have suffered from fatigue and mental fogginess, which were the side effects of his medication. So what did MetLife do with his short and longterm disability claim? Well, while they always do MetLife denied both the short and longterm disability claim on the basis that there was not enough clinical or objective evidence to substantiate a subjective complaints. They even claimed he was exaggerating his symptoms because his treating doctor commented that his symptoms were out of proportion to the exam findings and objective findings. Every one of MetLife's liar for hire doctors of pine , there was insufficient evidence of impairment. And as a result of the claims denial, he appealed and ultimately filed a lawsuit in federal court. What did the judge do with this evidence? Now it's clear that MetLife improperly conditioned benefits on the existence of objective evidence, even against the backdrop of homies, consistent and cooperated reports of chronic pain. The judge first looked at the totality of the evidence and found Hamid's symptoms to be credible. Now, the judge to his credit noted that the same treating doctor who said his symptoms were out of proportion, continued to recommend treatment, including surgeries. The judge reasoned that the continued recommendation for treatment supported the veracity and the intensity of amines symptoms. The judge also found objective evidence of disability because of the supporting letters from his treating physicians and supporting statements from friends, family, and coworkers. These documents further establish that Hamid was honest about the nature of his symptoms. And after finding that his symptoms were credible, the judge closely reviewed the medical records and look for objective evidence of disability. Now, the judge noted that MetLife had misconstrued Hamid's lengthy medical history, failing to credit numerous objective indicators of pain. The judge was impressed by the fact that he had gone to great lengths to relieve his symptoms. He had sought out and gotten pain management treatment. He had undergone Botox, injections, allergy injections, and surgery. He'd taken powerful medications, including opioids and academy, which in the judge's opinion were objective evidence of disability and impairment. As a result of finding a Mead symptoms, being credible, the great lengths to which he had gone to get treatment. The nature of the treatment, the judge awarded short-term disability benefits and 24 months of own occupation long-term disability benefits. You can see having the support of your physician and documentation of your symptoms and your problems with functionality are key to winning a disability claim. Let's take a break.

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Nancy L. Cavey:

Welcome back to winning isn't easy. According knowledge is how a cardio pulmonary exercise test, not as a CPA is the gold standard for measuring the functional capacity of a disability insurance policy holder with fibromyalgia. But how a doctor's failure to explain the basis of the claim can do a claim, not withstanding the seatbelt. Now look, many courts don't require laboratory data to confirm the symptoms of fibromyalgia such as pain and fatigue. So they don't necessarily look for an objective basis of the diagnosis because there is not always an objective basis, even on physical examination, but the courts do agree that a disability care is entitled to have medical evidence of a physical disability that prevents the policy holder from performing the material and substantial duties of their own occupation and the disability carriers also entitled to an excalation of how and why the treating physician assigned the restrictions and limitations. But what happens if the treating physician doesn't provide that information? The disability carrier is going to have their own liar for hire doctors review the medical records. They're going to have the doctor wire fire doctor reach out to the treating physician for clarification. Now, if the treating doctor doesn't explain the basis of the diagnosis and the physical restrictions and limitations of quarters, Johnny got on great that the carrier has the legal right to reject that opinion and rely on the opinions of the peer review doctor. Now, as I've said, one of the most common defenses to a fibromyalgia disobey claim is a carrier's argument that there is no objective evidence of the fibromyalgia, and there is no objective evidence of the functional restrictions limitations. And sometimes carriers will take this a step further and have the policy holder undergo a not so independent evaluation by their handpicked doctor so that they can claim that they have thoroughly evaluated the fibromyalgia, claim it before tonight. So how does this play up ? Well, it doesn't always play out in the favor of a policy holder, but in the case of manifestor versus met life, which is an Oregon case , uh , it does impart . And let me explain the details of this case, Ms. Med fester was diagnosed with fibromyalgia. She had all the classic complaints of fibromyalgia, multiple trigger points, body-wide pain, brain fog, decreased energy. She stopped working and she applied for both the short and long-term disability benefits, which were denied by MetLife. She appealed and as part of her appeal, she underwent a CT pet test that measured her capacity for physical activity. The testing revealed that she had a limited threshold for performing even seated sedentary work. So MetLife then had her file reviewed by a rheumatologist who cited the seedbed results as objective measures that clearly distinguish between indolence and true disability and noted that the findings were consistent with her subjective complaints and objective findings on examination. So MetLife accepted that and paid her own occupation benefits. But when the standard of disability changed any occupation, they exercise their rights to a not so independent IME and MetLife had noted in the medical records that she was her Aly mother's primary caregiver, and MetLife went off to the races. You need to be careful about what you're telling your doctor. The IME said where the IME was paid to say she could do full-time sedentary work eight hours a day, and guess what happened? Her claim got denied. Now she filed an appeal that was also denied. And as a result, she ends up in federal court and she argued three things. One that MetLife improperly terminated her benefits and denied her claim without evidence of improvement to that. The IME in probably required objective data, not withstanding the results of the seatbelt and three that the C pet report was the gold standard for measuring and evaluating her functional capacity and fatigue. Now, the court throughout the denial, noting that the CT pet was considered in the fields of exercise science and medicine as the gold standard. Uh , and it was recognized by the American college of sports medicine, American heart association, American college of chest physicians, American thoracic society, and American medical association. They found that the C-PAP , which is a study that's normally based on two exercise tests on consecutive days , uh , was a standardized physical stressor and recognized. Now the court accepted that and the court also ultimately excepted , uh, her arguments and awarded claims, but the court also criticized her physician for not really addressing why the restrictions and limitations had been assigned. Uh, she was fortunate because most courts would have denied the claim and said, we've got to connect the, see pat in terms of her restrictions and limitations and our inability to do any occupation. Uh, but this court was sympathetic. So while , um, there she was awarded the benefits, I think there are a couple of lessons here. The first lesson is that every fibromyalgia policy holder should have a seat pet exam to document their restrictions limitations. Secondly, they should have their physician endorsed the results of the CT pet three. They should have their physician explain that the basis of the restrictions limitations are based not only on their clinical examination of you, based on the findings that you present, but that is also consistent with in correlates with the CPA exam. I really don't want the carrier to seize on the argument that there's no explanation for the seatbelt results and the restrictions and limitations, even though that would be self-evident. I hope that you have enjoyed this week's episode. If you like this podcast, consider liking our page, leaving a review and sharing it with family and friends. Remember this podcast comes out weekly, so stay tuned for next week's episode of winning isn't easy. Thanks.