MetLife and filing Long-term Disability Insurance Appeals

Do you need help filing a long-term disability appeal with Metlife?

Author: Attorney Lonnie Roach

MetLife, Inc. is the holding company for Metropolitan Life Insurance Company and one of the world’s largest global providers of insurance, annuities, and employee benefit plans.

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LTD disability disputes can be long and drawn out and few disabled people have the resources to fight a large insurance company. Get help today. Call 512-454-4000

The company began in 1863 as National Union Life and Limb Insurance Company, insuring Civil War soldiers and sailors against disabilities due to wartime injuries and illness.

In 1868, it shifted its focus to the life insurance business and became known as Metropolitan Life Insurance Company. The company introduced “industrial” or “workingmen’s” insurance in 1879 with policies issued in small amounts and premiums collected weekly at workers’ homes. By 1930, the company insured every fifth man, woman and child in the U.S. and Canada and later financed the construction of the Empire State Building.

In 2015, MetLife ranked number one on Fortune magazine’s list of Most Admired Companies in insurance under the Life and Health category.

Its revenue was 63.48 billion dollars in 2016 and it employed 58,000 people, serving 90 million customers in over 60 countries. MetLife markets a diverse mix of financial products including:

•   Life Insurance
•   Annuities
•   Dental
•   Vision
•   Accident and Health
•    Disability
•   Home and Auto

In addition to group disability plans provided through an employer or association, MetLife offers individual disability insurance that can replace a portion of a person’s income if they are unable to work. These products include MetLife Income Guard, OMNI Advantage and OMNI Essential.

If you have been denied disability benefits don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.

MetLife cautions all its customers to review their policy for its terms and definitions before submitting a claim.

Some policies consider you disabled when you are unable to perform your job duties, while others will pay only if you’re unable to perform in any job suitable for you based on your training, education and experience. Be aware that not all disabilities and illnesses are covered and an elimination period must be met before benefits can begin. The employer selects the elimination period in group plans, usually a period of 90 days or 180 days and also selects the maximum duration period for receiving benefits, typically two years, five years and to age 65.

There are a variety of ways to submit a claim to MetLife, including online, mail, phone and fax.

You will need written proof of your disability from your medical providers and any additional medical records with details of your disability. MetLife may also request a medical exam, at their cost, as well as financial information.

A claim for STD benefits should be filed immediately in order to receive a timely decision, but all claims for disability should be filed within 45 days of the disability date.

A Disability Claim form should be completed by the Employee, Employer, and the Attending Physician and MetLife advises that all forms be submitted together.

If it appears that an Employee’s disability will extend beyond his or her elimination period, a claim should be filed.

Claims should be submitted after the last date worked but as soon as possible to allow processing time before the first benefit payment. MetLife recommends reporting a claim no later than 8 weeks prior to the end of the disabled Employee’s LTD elimination period.

The following forms are required by MetLife to submit an LTD claim and can be found on their website:

•   LTD Claim Employee Statement
•   LTD Claim Employer Statement
•   LTD Claim Attending Physician’s Statement

Note that the above forms are not required if MetLife also manages an employee’s STD claim as information contained on the STD claim is evaluated as part of the LTD claim process.

Whether a group has only LTD with MetLife or STD and LTD with MetLife, if additional information is required to evaluate a claim, MetLife will contact the employee by phone regarding the required information.

It is the Employee’s responsibility to provide all requested information. When a claim determination is made, the Employee is notified by phone and in writing and the Employer is notified in writing.

MyBenefits provides Employees with a personalized view of their MetLife benefits. With MyBenefits the Employee is able to:

•   View their disability income coverage
•    File a claim online
•   Download claim forms
•   View claim status and details online
•   View last payment issued

Access MyBenefits at: www.metlife.com/mybenefits.

If MetLife denies your claim, you will receive a letter stating the reason for denial and the procedure for appeal.

Because MetLife long-term disability group policies are provided by or purchased through an employer, they are governed by The Employee Retirement Income Security Act or ERISA which requires a claimant to “exhaust administrative remedies” before filing suit. Claimants have 180 days to appeal and insurers have 90 days to consider the appeal which equals 270 days a disabled person is without income. Claimants may be advised to file for Social Security Disability Income when filing a claim, but insurers may deduct any Social Security Income from insurance benefits and, if a claimant does not file for SSDI, the insurer may claim the disabled person has breached an LTD policy requirement. ERISA permits insurers to administer their own plans and a denial can only be reversed by demonstrating that the insurer abused that discretion – which is very difficult to do. If an internal appeal is denied, filing suit in U.S. District Court is a claimant’s last option.

Metlife Claim:

According to the denial letter, MetLife did not dispute that another San Antonio client was totally disabled, but rather that his disability was limited by the policy’s 24-month limitation for disabilities caused by Neuromusculoskeletal and soft tissue disorders. We challenged this classification of our client’s symptoms, arguing that our client did not have a Neuromusculoskeletal and soft tissue disorder and had never based his claim on this condition. He did suffer from Grade 3-Grade 4 chrondromalacia of the patella, a torn rotator cuff, and severe osteoarthritis of the knees and shoulder. According to the Social Security’s guidelines pertaining to these two separate disabling conditions, our client’s disability should have been classified as major dysfunction of a joint and reconstructive surgery or surgical arthrodesis of a major weight-bearing member. He could barely walk, could not lift more than 5 pounds, and was home-bound. We appealed his denial and got benefits reinstated.

Author: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.