• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • LinkedIn
  • YouTube

OLF Ortiz Law Firm National Disability Attorneys

Ortiz Law Firm is dedicated to helping people recover the disability benefits they deserve. We handle group Long Term Disability (LTD) claims, individual disability insurance policy claims, ERISA disability claims, and Social Security Disability claims.

  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT

Mobile Menu

Call us today for help!

(888) 321-8131
  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT
You are here: Home / Case Summary Blog / Randall v. MetLife – Doctor’s Conclusion Outweighs Subjective Complaints

Randall v. MetLife – Doctor’s Conclusion Outweighs Subjective Complaints

April 27, 2020 //  by Ortiz Law Firm//  Leave a Comment

Case Name: Randall v. Metropolitan Life Insurance Company

Court: United Stats District Court for the Northern District of California

Date of Decision: February 6, 2017

Type of Claims: Short term disability, long term disability, and related health, dental, vision, and life insurance benefits.

Insurance Company: Metropolitan Life Insurance Company, aka MetLife.

Claimant’s Employer: Verizon Wireless

Claimant’s Occupation / Job Position: Facilities Network Engineer

Disabilities: Randall suffers from “a longstanding condition of chronic and severe mid back pain,” which has progressed over time. She has a history of breast cancer and has received diagnoses of anterolisthesis, cervical disc disease, osteoporosis, lupus, myofascial pain syndrome, anxiety, and depression. Randall now alleges that her back pain is exacerbated by sitting, standing, reaching, or keyboarding and that her pain, fatigue, and impaired concentration due to pain medication make it impossible for her to perform the essential functions of her job.

Definition of Disability Under the STD Plan:  Randall’s plan provided for Short Term Disability benefits for up to 26 weeks if she was found to be totally disabled. A “Total Disability” is defined under the plan as follows:

You are considered totally disabled under the Plan for purposes of [Short Term Disability] benefits if, as a result of illness, injury or pregnancy, MetLife determines that you meet all of these conditions:
• You are absent from work for at least 8 full consecutive calendar days beginning with and including your first day absent from work because you are unable to perform for any Employer the Essential Functions of Your Occupation1 for which you are qualified by training, education or experience; and
• You have provided to MetLife objective medical evidence that sufficiently evidences, as determined by MetLife, that you cannot perform the Essential Functions of Your Occupation for which you are qualified by training, education or experience for any Employer. Your ability to get to and from the work place is not considered when determining whether you cannot perform the Essential Functions of Your Occupation if driving is not an Essential Function of Your Occupation . . .
• You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and
• You are unable to earn more than 80% of your pre-disability earnings at Your Occupation; and
• You are not engaged in any job/occupation, including self-employment, during the [Short Term Disability] application process or while you are receiving [Short Term Disability] benefits; and
• All information or documents to be considered has been received during the Initial Administration Period of your . . . claim.

Other Important Provisions: The Plan stated that Randall was “responsible for proving [her] disability claim.” Id. It instructed that she “must return a signed authorization form to MetLife allowing [her] Physician(s) to release objective medical evidence to substantiate [her] condition and ongoing treatment, as determined by MetLife,” and that benefits would automatically “be denied if [she or her] doctor or qualified practitioner fails to provide objective medical evidence in support of [her] claim within the time period specified by MetLife.” Id. The Plan specifically stated that “[a] physician’s note stating” that Randall “should not work is not objective medical evidence sufficient to prove [her] claim.”

The Plan specifically stated that “[a] physician’s note stating” that Randall “should not work is not objective medical evidence sufficient to prove [her] claim.”

The Plan provided some guidance as to objective medical evidence:

Objective medical evidence is necessary to clinically substantiate your condition and includes, but is not limited to:
• A diagnosis of your medical condition.
• Objective findings such as test results, X rays or operative notes supporting your claim for benefits.
• Any other information related to your individual circumstances that MetLife determines is necessary to decide whether your claim should be approved or denied.
• You and/or your Physician(s) may be required to provide additional information to substantiate ongoing treatment and/or evidence to support your continuing claim for short term disability benefits. The costs associated with providing this information are your responsibility.

Definition of Disability Under the LTD Plan: The LTD Plan’s summary plan description (“SPD”) explains that “You will be eligible for LTD [Long Term Disability] benefits if you are continuously disabled and unable to return to work after receiving [Short Term Disability] benefits for 26-weeks—provided you are certified as disabled under the LTD benefit component of the Managed Disability Plan and meet all other requirements detailed below.” The relevant sections of the Plan define LTD as follows:

You are considered disabled if MetLife determines that you have experienced, on or after the effective date of your LTD coverage under the LTD benefit component of the Managed Disability Plan, a significant change in your physical or mental condition as a result of accidental injury, sickness, mental illness, substance abuse or pregnancy.

Under the LTD benefit component of the Managed Disability Plan, an employee is considered to be “disabled” when the employee is absent from work because of an impairment for which there is sufficient objective medical evidence that supports:

For the first 24 months beginning with the LTD Effective Date:
• The employee cannot perform the Essential Functions of his or her job at Verizon Wireless.
• The employee cannot perform the Essential Functions of his or her occupation for which he or she is qualified by training, education or experience for any Employer.
For the period after the first 24 months beginning with the LTD Effective Date:
• The employee cannot perform the Essential Functions of any occupation for which he or she is qualified by training, education, or experience for any Employer.

During the period of disability, the employee must:
• Be receiving Appropriate Care and Treatment and complying with the requirements of such treatment;
• For LTD benefits, during the qualifying period and the next 24 months of sickness or accidental injury, the employee must not be able to earn more than 80% of the employee’s pre-disability earnings at the employee’s own occupation for any employer in the employee’s local economy. After the expiration of the qualifying period and the next 24 months, the employee must not be able to earn more than 60% of the employee’s pre-disability earnings from any employer in the employer’s local economy at any Gainful Occupation for which the employee is reasonably qualified taking into account the employee’s training, education and experience.

The LTD Plan also speaks to “Disability Due to Mental or Nervous Disorders or Diseases, Neuromusculoskeletal and Soft Tissue Disorders, Chronic Fatigue Syndrome and Related Conditions.” The Plan limits benefits for disability caused by mental or nervous disorders or neuromusculoskeletal and soft tissue disorders to a maximum of 24 months.

Randall’s plan also indicates, however, that the “certificate of insurance” governs the determination of her Long Term Disability benefits. The certificate of insurance states:

Disabled or Disability means that, due to Sickness or as a direct result of an 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.

Benefits Paid? MetLife approved Short Term Disability benefits for Randall for the period between April 15, 2013, through May 6, 2013, but communicated to Randall on June 15, 2013, that benefits would not be approved beginning May 7, 2013.

Issues: The Court determined whether Randall “was entitled to benefits based on the evidence in the administrative record and ‘other evidence as might be admissible… .”

Holdings: “The Court concludes that Randall has failed to prove by a preponderance of the evidence that she was disabled from May 7, 2013, onward and therefore that MetLife did not err in denying her benefits.”

Noteworthy court comments: “While it is clear that Randall was diagnosed with several conditions and was experiencing pain, she has not proven that she was disabled and unable to perform the essential functions of her job.”
…
“Randall argues, in essence, that her consistent reports of pain and resulting diagnoses should be sufficient to establish by a preponderance of the evidence that she was disabled. Her consistent reports of subjective pain are not sufficient to find disability in the face of her doctors’ uniform conclusions that she should return to work.”

Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.

Here is a PDF copy of the decision: Randall v. MetLife

FacebookTweetPinLinkedInPrintEmail

Category: Case Summary Blog, Long Term DisabilityTag: MetLife

Recent Posts

  • How to Win a Long Term Disability Appeal: Do’s and Don’ts
  • 3 Steps You Must Take Right Now If Your LTD Benefits Are Terminated!
  • Leveraging the Grid Rules to Secure SSDI Benefits After Age 50
  • What Is an On-The-Record Decision in a Social Security Disability Claim?
  • Understanding the Difference Between Diagnosis and Functional Impairment in Long Term Disability Claims
Previous Post: « Court Rules Insurer Cannot Ignore A Claimant’s Job Duties During Own Occupation Period
Next Post: Important Changes for Long Term Disability in 2019 and 2020 »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

Top Ten Mistakes That Will Destroy Your Long Term Disability Claim

View All Resources

"I highly recommend Ortiz Law Firm. Very friendly staff. They helped me win my appeal against Liberty Mutual. Thank you all for being the best!!"

Lavanda T.

View All Testimonials

Learn More About Long Term Disability

  • Areas We Serve
  • Frequently Asked Questions
  • Denials and Appeals
  • Your Chances of Getting Approved
  • Medical Eligibility
  • Additional Parts That Do Not Happen in Every Case
  • Medical Conditions That May Qualify
  • Long Term Disability Insurance Carriers
  • Occupations That May Qualify
  • LTD Federal Court Case Summaries

Footer

Contact Us

Our experienced disability law firm is ready to fight for you. Contact us today for a free case evaluation.

(888) 321-8131
316 S Baylen St., Ste 590
Pensacola, FL 32502

  • Email
  • Facebook
  • LinkedIn
  • YouTube

Claims We Handle

  • Group Long Term Disability
  • ERISA Disability Claims
  • Individual Disability Insurance
  • Social Security Disability Claims
  • Long Term Care Insurance
  • Florida Personal Injury

Quick Links

  • About Us
  • Free Resources
  • Client Testimonials
  • Case Results
  • Nationwide Representation
  • Refer a Case

Site Footer

© 2023 Ortiz Law Firm

Sitemap | Disclaimer | Privacy Policy

Share this ArticleLike this article? Email it to a friend!

Email sent!