This definitely gives the impression that MetLife is learning somemthing from UNUM, who has been playing hanky panky with disability claim denials and stonewalling for years. Their claims managers and staff are rewarded with bonuses for reaching $$ threshholds in denials.
This was reported at:461 F.3d 660. The disease was “severe dilated cardiomyopathy.” This is a disease of the heart muscle that causes the heart to become enlarged and, for that reason, to pump inadequately. Plaintiff, who worked as a sales manager in a women’s clothing department, began receiving LTD benefits after it was determined that she could not perform the duties of her regular job as a result of severe dilated cardiomyopathy. The administrator terminated the benefits on the ground that plaintiff’s condition had improved to the point that she was no longer “totally disabled.” The court, however, concluded that the administrator’s determination could not be sustained because it was not the product of a principled and deliberative reasoning process. The administrator acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, the administrator offered no explanation for crediting a brief form filled out by plaintiff’s treating physician while overlooking his detailed reports. Moreover, there was no adequate basis for the administrator’s decision not to factor in the major consideration of the role that stress played in aggravating plaintiff’s condition. Taken together, these factors reflected an arbitrary and capricious decision.
Reading the comments is quite interesting. The issue is difficult and polarizing. I am a claims person and thus I may be biased. I think that I am balanced. Just because a premium has been paid there is no guarantee that the insured claimant will be truthful, candid or forthcoming. And, it would be axiomatic that an irritating claimant would not get the same quality or level of concern and service as one who was cooperative. Still, the issue becomes a medical issue. I am willing to bet heavily that Met has a medical opinion from a highly respected medical practitioner. On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. The claimant knows but it is not in her best interest to share the truth. And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.
I look forward with a great deal of interest in the Court’s ruling.
here’s another factor in the case: if they say improved – are they stating that she can work if so where? if so, are they planning to retrain? problem is that the disability insurance is based on the ability to complete the job she was doing or starting. the insurance has to get a medical statement that states she can continue the work she was doing prior to the disability. if not, the company could save themselves money (not the insurance company) by offering her a job, where she can continue to work for the company. all companies want to make a profit. its just a matter of where do we draw the line. there are many folks i believe that live on disability but yet can be retrained to work and be beneficial to society. many of those folks would rather sit for free money for the gov’t. this is a great way for them to earn and give back to the community. this would help the economy. now there are those who are not able to work anymore, but there are many who can.
Apparently MetLife did not even give the full medical reports to the experts they relied on in their denial — only a brief portion that supported the denial. The Sixth Circuit said. “MetLife’s decision to deny long-term benefits in this case was not the product of a principled and deliberative reasoning process. MetLife acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, it offered no explanation for crediting a brief form filled out by Dr. Patel while overlooking his detailed reports. This inappropriately selective consideration of Glenn’s medical record was compounded by the fact that the occupational skills analyst and the independent medical consultant were apparently not provided with full information from Dr. Patel on which to base their conclusions.”
SS ‘threshold of disability’ is extremely high. 99.9% of claimants are denied the first time. They must go to court and provide mountains of paperwork to prove that they are unable to work in any field. Not just the field they are trained in. There also has to be proof that there is no chance of recovery.
I know three people that actually went through the process. It takes two- three years (paid retroactively if you win), and then the attorneys get a chunk of what you do get.
So if this woman can prove that her illness is never going to improve (with that specific illness even walking 10 feet or climbing 5 stairs could be an issue) and she would risk heart failure (which is a symptom of the disease) by attempting to work sufficiently to the Fed Gov’t, it is understandable that Metlife was out of line in deciding on their own that she was ‘better’.
The insuring agreement containing the definition of disability should be the basis on which to grant or deny a claim. Then the facts about the injury or disease and extent thereof should support decision based on the definition of disability. If in fact, her condition had changed for the better, and she was able to resume work, she should not be entitled to the money. I think we are getting too much into an entitlement mentality in this country. If not, then continue benefits. What’s the problem?
If we let doctors decide they’ll decide on weekly “heat treatments” and “massage therapy” indefinitely, not all doctors are honest, they’re subject to human nature & greed too, they have a conflict of interest too.
What’s needed is precise contracts with precise definitions and reliable contract enforcement.
I was a worker’s comp investigator, 90% of the cases I workered were fraud or their injuries & abilites were wildly exaggerated.
Lets face it humans lie when its in their best interest and there’s no penalty and right now there’s no penalty for lying or exagerating your injuries.
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This definitely gives the impression that MetLife is learning somemthing from UNUM, who has been playing hanky panky with disability claim denials and stonewalling for years. Their claims managers and staff are rewarded with bonuses for reaching $$ threshholds in denials.
This was reported at:461 F.3d 660. The disease was “severe dilated cardiomyopathy.” This is a disease of the heart muscle that causes the heart to become enlarged and, for that reason, to pump inadequately. Plaintiff, who worked as a sales manager in a women’s clothing department, began receiving LTD benefits after it was determined that she could not perform the duties of her regular job as a result of severe dilated cardiomyopathy. The administrator terminated the benefits on the ground that plaintiff’s condition had improved to the point that she was no longer “totally disabled.” The court, however, concluded that the administrator’s determination could not be sustained because it was not the product of a principled and deliberative reasoning process. The administrator acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, the administrator offered no explanation for crediting a brief form filled out by plaintiff’s treating physician while overlooking his detailed reports. Moreover, there was no adequate basis for the administrator’s decision not to factor in the major consideration of the role that stress played in aggravating plaintiff’s condition. Taken together, these factors reflected an arbitrary and capricious decision.
Reading the comments is quite interesting. The issue is difficult and polarizing. I am a claims person and thus I may be biased. I think that I am balanced. Just because a premium has been paid there is no guarantee that the insured claimant will be truthful, candid or forthcoming. And, it would be axiomatic that an irritating claimant would not get the same quality or level of concern and service as one who was cooperative. Still, the issue becomes a medical issue. I am willing to bet heavily that Met has a medical opinion from a highly respected medical practitioner. On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. The claimant knows but it is not in her best interest to share the truth. And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.
I look forward with a great deal of interest in the Court’s ruling.
here’s another factor in the case: if they say improved – are they stating that she can work if so where? if so, are they planning to retrain? problem is that the disability insurance is based on the ability to complete the job she was doing or starting. the insurance has to get a medical statement that states she can continue the work she was doing prior to the disability. if not, the company could save themselves money (not the insurance company) by offering her a job, where she can continue to work for the company. all companies want to make a profit. its just a matter of where do we draw the line. there are many folks i believe that live on disability but yet can be retrained to work and be beneficial to society. many of those folks would rather sit for free money for the gov’t. this is a great way for them to earn and give back to the community. this would help the economy. now there are those who are not able to work anymore, but there are many who can.
Apparently MetLife did not even give the full medical reports to the experts they relied on in their denial — only a brief portion that supported the denial. The Sixth Circuit said. “MetLife’s decision to deny long-term benefits in this case was not the product of a principled and deliberative reasoning process. MetLife acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, it offered no explanation for crediting a brief form filled out by Dr. Patel while overlooking his detailed reports. This inappropriately selective consideration of Glenn’s medical record was compounded by the fact that the occupational skills analyst and the independent medical consultant were apparently not provided with full information from Dr. Patel on which to base their conclusions.”
SS ‘threshold of disability’ is extremely high. 99.9% of claimants are denied the first time. They must go to court and provide mountains of paperwork to prove that they are unable to work in any field. Not just the field they are trained in. There also has to be proof that there is no chance of recovery.
I know three people that actually went through the process. It takes two- three years (paid retroactively if you win), and then the attorneys get a chunk of what you do get.
So if this woman can prove that her illness is never going to improve (with that specific illness even walking 10 feet or climbing 5 stairs could be an issue) and she would risk heart failure (which is a symptom of the disease) by attempting to work sufficiently to the Fed Gov’t, it is understandable that Metlife was out of line in deciding on their own that she was ‘better’.
The insuring agreement containing the definition of disability should be the basis on which to grant or deny a claim. Then the facts about the injury or disease and extent thereof should support decision based on the definition of disability. If in fact, her condition had changed for the better, and she was able to resume work, she should not be entitled to the money. I think we are getting too much into an entitlement mentality in this country. If not, then continue benefits. What’s the problem?
so does that matter based on medical decisions? and whose doctor is correct? her’s or the insurance company? or do we have to get an arbitrator?
Lou is absolutely right. Now we get to wait to see if the supremes agree
If we let doctors decide they’ll decide on weekly “heat treatments” and “massage therapy” indefinitely, not all doctors are honest, they’re subject to human nature & greed too, they have a conflict of interest too.
What’s needed is precise contracts with precise definitions and reliable contract enforcement.
I was a worker’s comp investigator, 90% of the cases I workered were fraud or their injuries & abilites were wildly exaggerated.
Lets face it humans lie when its in their best interest and there’s no penalty and right now there’s no penalty for lying or exagerating your injuries.