MetLife Disability Denials And Appeals

Disability denials from MetLife can leave individuals feeling lost and unsure of their next steps. If you’ve received a denial letter, it’s critical to act quickly and strategically to appeal the decision. Understanding your rights and the reasons for the denial can empower you to craft a compelling appeal that effectively addresses the insurer’s concerns.

You’re not alone in this difficult situation. Our goal is to provide you with the knowledge and resources to navigate the appeals process with confidence. Join us as we explore the nuances of MetLife disability denials, unravel the appeals process, and arm you with the tools to mount a strong and persuasive appeal. Your journey to overturning a denial and securing the benefits you rightfully deserve begins here.

About MetLife Long-Term Disability Insurance

Metropolitan Life Insurance Company, also known as MetLife, offers a variety of insurance policies, including short- and long-term disability insurance coverage. Disability insurance provides financial support if you are unable to perform your job duties due to an injury or illness. Unfortunately, a MetLife disability insurance policy does not guarantee that your claim for disability benefits will be approved.

It may be disconcerting to think that even if you had to stop working because of a serious injury or illness, MetLife could still deny your disability claim. And even if you initially qualify for disability benefits, MetLife could wrongfully terminate your claim. Fortunately, claimants can fight back against wrongful disability denials by going through the appeals process.

That’s where we come in. Nick Ortiz is a national disability attorney with the knowledge and experience to help you navigate the MetLife long-term disability claim denial and appeals process. We’re here to fight back against the insurance company so you can focus on what’s important – your health. Call the Ortiz Law Firm at (888) 321-8131 to schedule your free case evaluation today.

Understanding MetLife Disability Denials

Like all insurance companies, MetLife seeks to profit by carefully monitoring claims to reduce financial risk. When it comes to long-term disability claims, MetLife stands out for its aggressive review and scrutiny of the medical evidence supporting each claim. Common reasons for claim denials include:

Failure to Meet the Definition of Disability

One of the primary reasons for a MetLife disability denial is failure to meet the insurer’s definition of disability. MetLife has specific criteria and guidelines for determining disability, and if your medical condition does not meet their definition, your claim may be denied. Most MetLife policies have a definition of disability that changes after a certain period of time, usually 24 months.

Disability benefits are often terminated when the definition changes. Disability claims are often denied when the definition of disability changes from “own occupation” to “any occupation”. The differences are technical and confusing, and the insurance company will try to confuse claimants.

Here is a sample clause from a MetLife long-term disability policy:

“Disabled or Disability means that, due to Sickness or as a direct result of accidental injury:

You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and

You are unable to earn:

• During the Elimination Period and the next 24 months of Sickness or accidental injury, more than 80% of Your Predisability Earnings at Your Own Occupation from any employer in Your Local Economy; and
• After such period, more than 80% of your Predisability Earnings from any employer in Your Local Economy at any gainful occupation for which You are reasonably qualified taking into account Your training, education, and experience.”

Your Disability is Due to a Pre-Existing Condition

If your disability is considered to be the result of a pre-existing condition, MetLife may deny your claim. It’s important to provide clear documentation and evidence to show that your current disability is not a direct result of a pre-existing condition.

Insufficient Medical Evidence

Insurance companies like MetLife often deny claims because there is insufficient evidence to support the claim. It’s important to provide comprehensive medical records, test results, and statements from healthcare providers to support your claim and demonstrate the severity of your condition. A letter from your doctor simply stating that you are unable to work is insufficient.

For example, in a case involving back pain, you may need an x-ray, or perhaps an MRI or a CT scan would be better evidence. In a mental illness claim, you may need a neuropsychological evaluation to show cognitive deficits or difficulty thinking and processing information. This is the type of evidence an insurance company looks for when evaluating an LTD claim.

MetLife’s Medical Consultant Says You Are Not Disabled

MetLife often consults with medical professionals to evaluate disability claims. If their medical consultant determines that you are not disabled based on their evaluation, your claim may be denied. It’s important to get a second opinion or provide additional evidence to support your case.

Our Results: LTD Claim for Doctor with Short-Term Memory Problem Approved

MetLife terminated this claim based on reports from MetLife’s in-house psychologist and an independent medical examination. We worked with the claimant’s treating provider to dispute these reports and obtained updated medical records to submit along with a detailed appeal letter. Shortly after our appeal, MetLife reinstated the claim.

Discrepancies in Your Vocational Evaluation

Discrepancies in the definition of your occupation during a vocational evaluation can result in a denial of your disability claim by MetLife. Make sure your job duties and restrictions are accurately represented during the evaluation process to avoid misunderstandings that could lead to a denial.

MetLife Surveillance Tactics

MetLife may use surveillance tactics, such as monitoring your social media activity or conducting in-person surveillance, to evaluate the validity of your disability claim. It’s important to be careful about what you share online and to be transparent about your limitations to avoid potential denials based on surveillance findings.

You Have Received the Maximum Benefits for Your Condition

Most policies limit the duration of benefits for claimants who are disabled due to a mental or nervous disorder. Once a claimant has exhausted their “lifetime maximum” of benefits for such a condition, benefits are terminated unless the claimant can prove that they also have a disabling condition that is not subject to the policy limitation. However, it is not uncommon for insurers to ignore a claimant’s physical limitations and focus primarily on mental limitations in order to terminate claims based on the mental and nervous disorder limitation.

Here is a sample clause from a recent MetLife policy:

“If You are Disabled due to one or more of the following medical conditions described below, We will limit Your Disability benefits to a lifetime maximum equal to the lesser of:

• 24 months for one period of Disability during Your lifetime for any one or more, or all of the above conditions; or
• the Maximum Benefit Period.

Subject to the Administration of Limited Disability Benefits for Disability Due to Mental and Nervous Disorders or Diseases as set forth below:

Your Disability benefits will be limited as stated above for:

1. Disability due to alcohol, drug or substance abuse or addiction, We require You to participate in an alcohol, drug or substance addiction recovery program recommended by a Physician. We will end Disability benefit payments at the earliest of the period described above or the date You cease, refuse to participate, or complete such recovery program.
2. Mental or Nervous Disorder or Disease that results from any cause, except for:
   • Neurocognitive Disorders.”

Policy limitations may also apply to claims for certain physical impairments. It is becoming increasingly common for insurers to limit claims for long-term disability benefits for conditions that are considered neuromuscular, musculoskeletal, and soft tissue disorders.

How to Appeal a MetLife Disability Denial

If MetLife has denied your claim for long-term disability benefits, you should first understand that the decision to deny a disability benefits claim is not final. You have the right to appeal a long-term disability denial, and the insurer must conduct a full and fair review of your claim promptly.

Claimants should take immediate action to appeal the decision. Let’s review the steps necessary to effectively appeal a MetLife disability denial.

Review the Denial Letter

When you receive a denial letter from MetLife, carefully review the document to determine why your claim was denied. The explanation may help shed light on the evidence needed to support your claim for long-term disability benefits.

If you’re not sure why your initial claim was denied, our experienced legal team can help you understand the reasoning behind your claim denial. We can also help you determine what medical records or other evidence may have been missing from your original claim for long-term disability benefits.

Gathering Additional Medical Evidence

Filing an appeal with the insurance carrier should not be taken lightly. Long-term disability attorneys do not simply send a short letter to the insurance companies stating, “We are appealing”. We know that is completely inadequate and will only result in MetLife upholding the decision to deny your claim. The administrative appeal process requires you to submit new evidence.

To strengthen your appeal, you should gather additional medical evidence to support your disability claim. This may include medical evidence from your treating physician, statements from friends and family, and even statements from the claimant. Your appeal to MetLife may consist of some or all of the following:

• Updated medical records;
• Letters from medical experts supporting your claim;
• Your statement;
• Statements from friends, family, and co-workers;
• Results of a functional capacity evaluation and
• Residual functional capacity forms.

Long-term disability attorney Nick Ortiz and his experienced legal team at the Ortiz Law Firm assist clients with administrative appeals by gathering all the necessary documentation and preparing comprehensive appeal letters to give his clients the best chance of successfully obtaining benefits from MetLife. If you have any questions or concerns during the appeal process, our experienced legal team is available to assist you.

If you are proceeding with the appeal process without an attorney, you need to understand the importance of submitting sufficient documentation to support your claim. We encourage you to review our free Disability Insurance Appeal Guide before you begin. It explains the importance of filing a well-supported appeal and provides a step-by-step guide to the disability insurance appeal process, RFC forms, appeal letter templates, and more.

File an Appeal on Time

Pay close attention to all instructions provided by MetLife on how to appeal the decision. MetLife has strict deadlines for submitting appeals following a denial. It is important to meet these deadlines to ensure that your appeal is considered, as missing the deadline could result in your appeal being denied. Keep track of the timeline and submit your appeal before the due date.

Our Results: “Any Occupation” Claim Approved for Claimant with Chronic Pain

Our client had been receiving LTD benefits from MetLife for two years when the definition of disability changed from “own occupation” to “any occupation.” MetLife’s medical director determined that the claimant could perform other work, so the claim was terminated. We obtained additional evidence, appealed, and the claim was reinstated.

Writing a Strong Appeal Letter

When preparing your appeal, write a compelling and persuasive appeal letter to MetLife. Clearly outline why you believe your disability claim is valid and address any reasons cited in the denial letter. Use clear and concise language to effectively communicate your points. Highlight key medical evidence and explain how it supports your claim.

Preparing for a Possible Lawsuit

If MetLife is still trying to avoid paying your claim and has also denied your administrative appeal, you may have the option of filing a second appeal (if your policy allows it), or you may have to resort to filing a lawsuit. A legal professional who specializes in disability claims can help you understand the next steps in filing a lawsuit against MetLife. Be proactive in seeking legal advice to navigate the escalation of your case into a legal setting.

If your appeal is unsuccessful, be prepared to take further action by considering litigation. Depending on how you purchased your policy, you may have an ERISA claim, which means a lawsuit would be filed under the federal Employee Retirement Income Security Act of 1974 (ERISA).

ERISA Claims

It is likely an ERISA claim if you received your policy as part of a group employee benefit plan. ERISA governs many disability claims. In an ERISA disability denial case, a federal judge will review your claim and all the evidence the company used in deciding whether to deny your claim, and then determine whether MetLife’s decision to deny your claim for benefits was correct under the terms of the policy and the law. ERISA law can be very complicated and heavily weighted in favor of the insurance company, which is why so many claimants choose to work with an ERISA attorney who specializes in long-term disability.

MetLife Federal Court Case Summaries

The court cases summarized here are intended to help you understand how federal courts decide ERISA long-term disability claims.

• Schmill v. MetLife – Court Upholds 12-Month Limit on Benefits for Mental and Musculoskeletal Disorders
• Sutton v. MetLife – LTD Policy Requires Objective Evidence, Not Conclusive Proof
• Fowkes v. MetLife – Claimant Did Not Prove She Was Disabled
• Santana-Diaz v. MetLife – Court Rules That “Clinical” Is Not an Ambiguous Term
• Sumpter v. MetLife – Court Finds Plaintiff’s Lawsuit Frivolous
• Tash v. MetLife – Court Finds MetLife Subverted ERISA Process
• Seeman v. MetLife – Vice President Wins Long-Term Disability Claim
• Randall v. MetLife – Doctor’s Conclusion Outweighs Subjective Complaints
• Carty v. MetLife – Court Orders MetLife to Pay Claimant’s LTD Benefits
• Black v. MetLife – Social Media Surveillance Results in Termination of Benefits

Non-ERISA Claims

If you did not purchase your policy as part of a group employee benefits plan, you probably have a non-ERISA disability insurance policy. Claimants with non-ERISA policies can still file a lawsuit against their insurance providers for denying their long-term disability insurance claim. Still, it will not be governed by federal ERISA law.

We understand that insurance companies sometimes act in bad faith and will fight to protect your rights as a policyholder. We have experience filing suits against MetLife and many other insurance companies. Don’t hesitate to contact us if you want to learn more about how a long-term disability attorney can help

Schedule a Free Case Review

Nick Ortiz is an experienced MetLife long-term disability attorney who has helped hundreds of claimants recover benefits from MetLife and other major disability insurance companies. He and the skilled legal team at the Ortiz Law Firm will guide you through the long-term disability appeal process and work diligently to build up the medical evidence supporting your claim to improve your chances of winning it.

We offer a free case review to those who have been denied long-term disability benefits. During your free case evaluation, an attorney, Nick Ortiz, will review your MetLife denial letter, evaluate the policy terms and definitions used to deny your claim, and offer advice on how to proceed with your MetLife disability appeal.

There is absolutely no upfront cost. You only pay an attorney’s fee if we successfully recover your disability benefits. If your MetLife long-term disability claim has been wrongly denied or terminated, call us at (888) 321-8131 or click the button below to schedule a free case review with a MetLife disability attorney today.

Frequently Asked Questions