MetLife Long-Term Disability Denials And Appeals

MetLife long-term disability denials can leave individuals stranded and unsure of their next steps. If you’ve received a denial letter, acting promptly and strategically is crucial to appeal the decision. Knowing your rights and the grounds for denial can empower you to craft a compelling appeal that effectively addresses the insurer’s concerns. Our goal is to equip you with the knowledge and resources to navigate the appeals process confidently.

At the Ortiz Law Firm, we have a long history of success handling claims with MetLife. Over the years, we’ve managed hundreds of cases involving appeals, lawsuits, and settlements, giving us a deep understanding of how MetLife operates. We know their playbook inside and out—the strategies they use to deny claims, the defenses they rely on, and the methods they use to delay payments. This knowledge allows us to craft the strongest possible case for our clients.

Attorney Nick Ortiz has also developed strong professional relationships with the defense attorneys regularly hired by MetLife. He regularly communicates with many of these lawyers, allowing him to cut through the red tape and get straight to productive discussions. With their personal contact information on hand, including cell phone numbers, he can connect with these attorneys directly to push negotiations forward. This level of access gives our clients a distinct advantage when it comes to resolving their claims.

You do not have to face a MetLife long-term disability claim denial alone. We’re here to pick up the fight against the insurance company so you can focus on what matters – your health. Call us at (888) 321-8131 to schedule your free case evaluation today.

About MetLife Long-Term Disability Insurance

Metropolitan Life Insurance Company, also known as MetLife, offers various insurance policies, including contracts for long-term disability insurance coverage. Disability insurance provides financial support if you cannot perform your work duties due to an injury or illness. However, obtaining a disability insurance policy from MetLife does not guarantee that your claim for disability benefits will be approved.

Understanding MetLife Long-Term Disability Denials

Like all insurance companies, MetLife aims to profit by carefully monitoring claims to reduce financial risk. Regarding long-term disability claims, MetLife stands out for its aggressive review and scrutiny of the medical evidence supporting each claim.

Common reasons for denying claims include:

Not Meeting the Definition of Disabled

One of the primary reasons for a disability denial from MetLife is not meeting the insurer’s definition of disabled. MetLife has specific criteria and guidelines to determine disability, and if your medical condition does not align with their definition, your claim may be denied. Most MetLife policies have a definition of disability that changes after a certain period, typically 24 months.

Disability benefits are often terminated after a change in definition occurs. Disability claims are frequently 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 deemed a result of a pre-existing condition, MetLife may deny your claim. It’s crucial to provide clear documentation and evidence to show that your current disability does not directly result from any pre-existing conditions.

Insufficient Medical Evidence

Insurance carriers like MetLife frequently deny claims because there is insufficient evidence to support the claim. It’s essential to provide comprehensive medical records, test results, and healthcare provider statements to support your claim and demonstrate the severity of your condition. A letter from your doctor simply stating that you are unable to work will not be sufficient.

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

MetLife’s Medical Consultant Claimed 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 assessment, your claim may be denied. It’s essential to seek 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 exam. 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 we submitted the appeal, MetLife reinstated the claim.

Discrepancies In Your Vocational Assessment

Discrepancies in defining your occupation during a vocational assessment can result in a denial of your disability claim by MetLife. Ensure that your job responsibilities and limitations are accurately represented during the evaluation process to avoid misunderstandings that could result in denial.

MetLife Employed Surveillance Tactics

MetLife may use surveillance tactics, such as monitoring your social media activity or conducting in-person surveillance, to assess the validity of your disability claim. It’s essential to be cautious about what you share online and 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 benefit period for claimants who are disabled due to a mental or nervous disorder. Once a claimant has utilized their “lifetime maximum” of benefits for such a condition, benefits will be terminated unless the claimant can prove that they also have a disabling condition 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 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.”

Insurance policy limitations may also apply to claims for specific physical impairments. It is becoming increasingly common for insurers to limit long-term disability benefit claims for conditions considered to be neuromuscular, musculoskeletal, and soft tissue disorders.

It may be troubling to think that even if you had to stop working because of a severe injury or illness, MetLife could still issue a disability claim denial. 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 administrative appeal process.

How to Appeal a MetLife Long-Term Disability Denial

If MetLife denied your claim for long-term disability benefits, you must 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 is supposed to conduct a full and fair review of your claim promptly.

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

Reviewing the Denial Letter

Upon receiving a denial letter from MetLife, carefully review the document for 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 lacking in your initial application for long-term disability benefits.

Gathering Additional Medical Evidence

Filing an appeal with the insurance carrier should not be taken lightly. Long-term disability lawyers do not just send a brief letter to the insurance companies stating, “We appeal.” We know that is wholly insufficient and would only result in MetLife upholding the decision to deny your claim. You must submit new evidence during the administrative appeals process.

To strengthen your appeal, gather additional medical evidence that supports your disability claim. Such documentation may include medical evidence from your treating physician, statements from friends and family, and even statements from the claimants. Your appeal to MetLife may consist of some or all of the following:

• Updated medical records;
• Opinion letters in support of your claim from medical experts;
• Your declaration;
• Declarations from friends, family, and co-workers;
• Results from 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 help 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 will be standing by to assist you.

RELATED POST: Why You Don’t Need an Attorney In Your State to Appeal an ERISA LTD Denial

If you are moving forward with the appeal process without an attorney, you must understand the importance of submitting sufficient documentation to support your claim. We encourage you to review our free disability insurance appeal guide before you get started. It will explain the importance of filing a well-supported appeal, and you will get a step-by-step guide to the disability insurance appeal process, RFC forms, appeal letter templates, and more.

Submitting an Appeal Within Deadlines

Pay close attention to any instructions provided by MetLife on how to appeal the decision. MetLife sets strict deadlines for submitting appeals following a denial. It is crucial to adhere to these deadlines to ensure your appeal is considered, as missing the deadline could result in your appeal being dismissed. 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 the claimant could perform other work, so the claim was terminated. We obtained additional medical evidence, filed an appeal, and the claim was reinstated.

Crafting a Strong Appeal Letter

Craft a compelling and persuasive appeal letter to MetLife when preparing your appeal. 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 convey your points effectively. 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 could have the option to file a second appeal (if your policy allows it), or you may have to resort to filing a lawsuit. A legal professional specializing in disability claims can help you understand the next steps for initiating a lawsuit against MetLife. Be proactive in seeking legal guidance to navigate escalating your case to a legal setting.

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

ERISA Claims

It is probably an ERISA policy if you obtained your policy as part of a group employee benefits 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 while deciding if your claim should be denied, then determine whether Met Life’s decision to deny your claim for benefits was proper under the terms of the policy and the law. ERISA law can be highly complicated and heavily favors the insurance company, so many claimants choose to work with an ERISA attorney specializing in long-term disability.

Non-ERISA Claims

If you did not obtain 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 to Get Help with Your MetLife Disability Denial

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 denied long-term disability benefits. During your free consultation, 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 proceeding with your MetLife disability appeal.

There are absolutely no upfront costs. You only pay an attorney’s fee if we successfully recover your disability benefits. If your MetLife long-term disability claim has been wrongfully denied or terminated, call our office at (888) 321-8131 to schedule your free review with a MetLife disability attorney today.

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FAQ: MetLife Disability Denials and Appeals