Case Story: Our Client v. Metropolitan Life Insurance Company
The plaintiff, worked as a sales representative for Georgia-Pacific until October 2002 when they had to stop working because of chronic lower back pain. Our client applied for and was awarded long term disability benefits beginning March 8, 2003. Id. at *2. During the first two years of benefits, the plaintiff only had to be disabled from their own occupation, but after the first two years of benefits, the plaintiff had to be disabled from any occupation to continue receiving benefits. Id. at *1.
In September 2004, MetLife, the insurance company, notified the plaintiff that it was reviewing their eligibility for continued long term disability benefits under the plan’s “any occupation” definition of disability. Id. at *3. MetLife requested updated documentation from the plaintiff’s treating physician, Dr. Standard. Id. After receiving the updated records from Dr. Standard, MetLife followed up with him but received no response. Id. A doctor hired by MetLife then reviewed the plaintiff’s file and issued a report stating that the plaintiff could do sedentary work. Id.
By letter dated March 9, 2005, MetLife notified plaintiff that their disability benefits were being terminated, effective March 7, 2005. Id. Furthermore, this letter told the plaintiff that they had 60 days to respond and request a review of their claim in writing. Id. Without hiring an attorney, the plaintiff responded by letter dated May 16, 2005. Id. Again via letter, in July 2005, MetLife affirmed its decision to terminate the plaintiff’s long term disability benefits and told the plaintiff that the decision to terminate their benefits was final and would not be reconsidered. Id. at *3.
The plaintiff hired us in December 2005, and we helped them obtain updated information. Id. at *4. We obtained updated medical records, an attending physician’s statement, as a sworn statement from one of their doctors. Id. We sent the information to MetLife and explained to them they should have given our client 180 days under the ERISA claims regulations under 29 C.F.R. § 2560.503-1. MetLife refused to reconsider its decision to deny benefits, so we sued MetLife under ERISA. Id.
In court, MetLife argued that it did not have to consider the new information we submitted because, even though they were supposed to give our client 180 days, giving him only 60 days was only a “slight deviation from the precise technical compliance with ERISA,” and that MetLife “substantially complied” with the purposes of ERISA as outlined in Kent v. United of Omaha Insurance Company, 96 F. 3d 803 (6th Cir. 1996). Id. at *5. Kent established that a technical failure to comply with ERISA’s procedural requirements could be excused if the purposes of ERISA were satisfied. Id.
The court did not agree with this argument. Id. at *6. Instead, the court found that only giving our client 60 days was “a serious procedural error [that] undermined administrative review of Plaintiff’s claim for benefits.” Id., at *4.
We argued that MetLife’s letter giving our client only 60 days to appeal caused substantive harm to their claim because they rushed to appeal the denial pro se (meaning they appealed without the help of an attorney), without supporting documentation. Id. at *6. The court explained, in agreeing with us, that the purposes of ERISA’s 180-day rule were not met by the insurance company. Id. at *6. The purposes of ERISA’s 180-day rule: to give a claimant the specific reasons for termination of benefits, to provide an opportunity for a full and fair review of the claim, and to ensure that a claimant had sufficient time to consider and prepare an appeal. Id. at *6 (citing Wenner v. Sun Life Assur. Co. of Canada, 482 F.3d 878, 882 (6th Cir. 2007); PENSION AND WELFARE BENEFITS ADMINISTRATION, 63 Fed.Reg. 48390, 48393 (Sept. 9, 1998)). The ERISA claims regulations applied here and directly stated that when an adverse benefit determination occurred, the claimant would have “at least 180 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination;…” Id. at *5 (citing 29 C.F.R. § 2560.503-1(h)(3)(i)).
MetLife tried to argue that there was no harm in giving our client only 60 days because they said they would have accepted additional documentation during the next 120 days. The court rejected that argument because the letter to our client told them that their appeal was final and that no further materials would be considered at the administrative level. Id. Nor did they tell them they could have sent in more information. Thus, the court explained, when our client appealed without an attorney, they had “no reasonable way of knowing their rights had been violated and that they had an additional 120 days in which to supplement their appeal.” Id. The court even described MetLife’s arguments, that they would have considered additional information if our client had sent it in, disingenuous. Id.
Because the court ultimately agreed with our arguments that MetLife’s failure to tell our client they had a full 180 days to appeal, as required by ERISA, was enough to overturn MetLife’s decision to deny, the court then ordered the case remanded to MetLife for a proper decision. Id. at *10.