Case Story: Our Client v. Metropolitan Life Insurance Company

We helped our client win their ERISA long term disability (“LTD”) benefits because the court agreed with our arguments that MetLife improperly denied our client’s benefits.   Without using the term “cherry-picking” the court agreed that MetLife acted arbitrarily and capriciously by relying on the evidence that supported its decision to deny benefits while ignoring the other information that supported our client’s claim.

Our client claimed disability due to fibromyalgia, chronic pain, and other conditions.  MetLife denied our client, saying there was not enough “objective evidence” of disability. The two doctors who reviewed our client’s file for MetLife, Dr. Schmidt, and Dr. Porter, did not examine our client, nor did MetLife hire any other doctor to examine them, even though it was permitted in the policy.  Also, the doctors who only reviewed their medical records said one of the reasons that our client was not disabled was that their complaints of pain and limitations were not credible in light of their condition.

The court agreed with our arguments that the insurance company was arbitrary and capricious because it failed to have the claimant examined, especially when part of the decision is based on an evaluation of the claimant’s credibility, as in this case.  The failure of MetLife to examine the claimant, especially when the right to do so is reserved in the Plan,  raised issues regarding the thoroughness and accuracy of the benefits determination.  Id. at 11, citing Calvert v. Firstar Finance, Inc., 409 F.3d 286 at 289 (6th Cir. 2005).

One of the doctors hired by MetLife stated he was not qualified to discuss the claimant’s mental diagnoses, and the other doctor did not discuss it. The court found, therefore, that MetLife completely disregarded the claimant’s diagnosis of mental illness, which was also arbitrary and capricious.

The court also agreed it was arbitrary and capricious for MetLife to agree with the opinions of the doctors it hired without taking into account the opinions of doctors who actually examined or treated the claimant.  MetLife was also arbitrary and capricious to not give more consideration to the effects of our client’s medications.

The court ultimately agreed with us that MetLife was wrong, and that our client was totally disabled and was eligible for LTD benefits.

One problem in this case that we had to work around was that the client was allowed to appeal twice by MetLife, and did so before they hired us.  MetLife told our client that the denial of the second appeal was their final decision and MetLife would not consider any additional information.  After that, the client hired us, and we determined there was other additional information that would help their case, so we obtained it and submitted it to MetLife.  The judge held that he could only look at the information submitted to MetLife during the appeal process so that the judge held he could not look at the new information.  Fortunately, our other arguments were successful that the records already submitted to MetLife, and the way MetLife wrongly handled the claim, were enough for us to help our client win this cases.  [This is an example why it is very important for someone to hire an experienced ERISA attorney to help with all the appeals in an LTD claim, and not wait until the claim is denied to hire an attorney who knows how to help someone with LTD cases]

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