Receiving a disability denial from MetLife can leave individuals feeling lost and unsure of their next steps. If you’ve received a denial letter, it’s crucial to appeal the decision quickly and strategically. Understanding your rights and the reasons for the denial can empower you to craft a compelling appeal that effectively addresses the insurer’s concerns.
Remember, 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, explain the appeals process, and equip you with the tools to create a strong, 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 various insurance policies, including short- and long-term disability insurance. Disability insurance provides financial support if you are unable to perform your job duties due to an injury or illness. Unfortunately, having a MetLife disability insurance policy does not guarantee that your claim for disability benefits will be approved.
It can be disconcerting to think that, even if you had to stop working due to a serious injury or illness, MetLife could still deny your disability claim. 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 turn a profit by carefully monitoring claims to reduce financial risk. When it comes to long-term disability claims, MetLife stands out because of how aggressively it reviews and scrutinizes 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. If your medical condition does not meet their definition, your claim may be denied.
Below 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.”
Most MetLife policies change their definition of disability from “own occupation” to “any occupation” after a certain period of time, usually 24 months. Thesetechnical differences are confusing and insurance companies exploit this to confuse claimants. Disability benefits are often terminated when the definition changes.
Pre-Existing Condition Exclusions
If MetLife considered your disability to be the result of a pre-existing condition, they may deny your claim. It’s important to provide clear documentation and evidence showing that your current disability is not a direct result of a pre-existing condition.
Insufficient Medical Evidence
Insurance companies like MetLife often deny claims due to insufficient evidence. It’s important to provide comprehensive medical records, test results, and statements from healthcare providers to support your claim. A letter from your doctor simply stating that you are unable to work is insufficient. You need medical evidence to demonstrate the severity of your condition.
For example, in a case involving back pain, an X-Ray, MRI, or CT scan would provide better evidence. For a mental illness claim, you may need a neuropsychological evaluation to demonstrate cognitive deficits or difficulty thinking and processing information. This is the type of evidence that insurance companies looks for when evaluating LTD claims.
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 denied the claim based on reports from their in-house psychologist and an independent medical examination. We worked with the claimant’s treating provider to dispute these reports, obtaining updated medical records to submit alongside a detailed appeal letter. Shortly after we submitted the appeal, MetLife reinstated the claim.
Discrepancies in Your Vocational Evaluation
Discrepancies in the definition of your occupation during a vocational evaluation can result in MetLife denying your disability claim. 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. 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 with 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 they have an additional 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 disorders.
Below 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:
- 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.
- Mental or Nervous Disorder or Disease that results from any cause, except for:
- Neurocognitive Disorders.”
Policy limitations may also apply to claims involving certain physical impairments. Insurers are increasingly limiting 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 claim, first understand that the decision is not final. You have the right to appeal the denial, and the insurer must promptly conduct a full and fair review of your claim.
Claimants should take immediate action to appeal the decision. Let’s review the steps necessary to effectively appeal a MetLife disability denial.
First, 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 helpyou understand what evidence is needed to support your claim for long-term disability benefits.
If you’re unsure why your initial claim was denied, our experienced legal team can help you understand the reasoning behind it. We can also help you determine what medical records or other evidence may have been missing from your original claim.
Gathering Additional Medical Evidence
Filing an appeal with the insurance carrier is not something that should be taken lightly. Long-term disability attorneys don’t just send a short letter to insurance companies saying, “We‘re appealing”. We know that would be completely inadequate and would 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, as well as statements from friends, family, and 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 coworkers;
- Results of a functional capacity evaluation; and
- Residual functional capacity forms.
Nick Ortiz, a long-term disability attorney, and his experienced legal team at the Ortiz Law Firm help clients with administrative appeals. They do this by gathering all the necessary documentation and preparing comprehensive appeal letters. This gives 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 help.
If you are proceeding with the appeal process without an attorney, it is crucial that you understand the importance of submitting sufficient documentation to support your claim. We encourage you to review our free Disability Insurance Appeal Guide beforehand. The guide explains why a well-supported appeal is important and provides a step-by-step guide to the disability insurance appeal process, RFC forms, and appeal letter templates.
File an Appeal on Time
Pay close attention to all instructions provided by MetLife regarding how to appeal the decision. MetLife has strict deadlines for submitting appeals following a denial. Meeting these deadlines is important to ensure that your appeal is considered; missing a 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 the decision, and the claim was reinstated.
Writing a Strong Appeal Letter
When preparing your appeal, write a compelling and persuasive appeal letter to MetLife. Clearly explain 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 continues to avoid paying your claim and denies your appeal, you may have the option of filing a second appeal (if your policy allows it) or filing a lawsuit. A legal professional who specializes in disability claims can help you understand the next steps in filing a lawsuit against MetLife. Seek legal advice proactively 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. This means that a lawsuit would be filed under the federal Employee Retirement Income Security Act of 1974 (ERISA).
ERISA Claims
You likely have an ERISA claim if you received your policy as part of an employer-sponsored group benefits plan. ERISA governs many disability claims. In an ERISA disability denial case, a federal judge will review your claim, as well as all the evidence the company to decide whether to deny your claim. Then, the judge will determine whether MetLife’s decision to deny your claim for benefits was correct, according to the policy terms and the law. ERISA law can be very complicated and heavily favors 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.
Non-ERISA Claims
If you did not purchase your disability insurance policy as part of an employer-sponsored benefits package, then you likely have a non-ERISA policy. Claimants with non-ERISA policies may file a lawsuit against their insurance providers for denying their long-term disability insurance claims. However, it will not be governed by federal ERISA law.
We understand that insurance companies sometimes act in bad faith, and we will fight to protect your rights as a policyholder. We have experience filing suits against MetLife and many other insurance companies. Contact us today 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. We work diligently to build up the medical evidence that supports your claim, which will improve your chances of winning.
We offer free case reviews 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 wrongfully 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
What are the most common reasons for MetLife disability denials?
Common reasons for MetLife disability denials include lack of sufficient medical evidence, failure to meet the policy’s definition of disability, failure to follow prescribed treatment, or failure to meet deadlines for submitting required documentation.
How do I appeal a MetLife disability denial?
To appeal a MetLife disability denial, you must gather any additional medical records or supporting documentation, follow the outlined appeal process, and submit your appeal within the specified timeframe. It is important to present a strong case with new evidence to support your claim.
Can I increase my chances of a successful appeal?
To increase your chances of a successful MetLife disability appeal, be sure to provide thorough and relevant medical evidence, meet all deadlines, and consider hiring a legal professional who specializes in disability claims.
How long does the MetLife disability appeal process take?
Generally, MetLife will give you 180 days to appeal a denial. However, the MetLife disability appeal review process can vary in length depending on the complexity of the case and the amount of additional information provided. It may take several months to receive a decision on your appeal.
Should I hire an attorney for my MetLife disability appeal?
While not required, hiring an attorney experienced in disability appeals can significantly increase your chances of a successful outcome. An attorney can help you navigate the complex appeals process, gather the necessary evidence, and present a compelling case on your behalf. And most attorneys only get paid if there is a recovery. At the Ortiz Law Firm, we never charge a fee unless your case results in compensation.
