{"id":7398,"date":"2020-04-30T05:27:16","date_gmt":"2020-04-30T10:27:16","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7398"},"modified":"2024-01-19T12:56:58","modified_gmt":"2024-01-19T17:56:58","slug":"tash-v-metlife-court-holds-that-metlife-undermined-the-erisa-process","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/tash-v-metlife-court-holds-that-metlife-undermined-the-erisa-process\/","title":{"rendered":"Tash v. MetLife &#8211; Court Holds That MetLife Undermined the ERISA Process"},"content":{"rendered":"<p><strong>Case Name:\u00a0<\/strong>Raymond M. Tash, DDS v. Metropolitan Life Insurance Company; Pacific Dental Services, Inc., Employee Benefit Plan<\/p>\n<p><strong>Court:\u00a0<\/strong>United States District Court Central District of California<\/p>\n<p><strong>Type of Claim:\u00a0<\/strong><a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/\">Long-Term Disability<\/a><\/p>\n<p><strong>Insurance Company:\u00a0<\/strong><a href=\"https:\/\/www.nickortizlaw.com\/insurance-companies\/metlife\/\">Metropolitan Life \u201cMetLife\u201d<\/a><\/p>\n<p><strong>Claimant\u2019s Employer:\u00a0<\/strong>Pacific Dental Services, Inc.<\/p>\n<p><strong>Claimant\u2019s Occupation \/ Job Position:\u00a0<\/strong><a href=\"https:\/\/www.nickortizlaw.com\/occupations-that-qualify-for-ltd\/dentists\/\">Dentist\/Doctor of Dentistry<\/a><\/p>\n<p><b>Disabilities: <\/b>There was no mention of his specific disabilities\/conditions- it just said he had multiple injuries.<\/p>\n<p><strong>Definition of Disability: <\/strong>The Plan defines Disability for LTD purposes for the first two years as: \u201cemployee\u2019s inability to perform his \u2018own occupation.\u2019\u201d<\/p>\n<p>The Plan allows an employee to receive LTD benefits beyond two years if the employee \u201cis unable to earn 60% of his prior earnings in \u201cany gainful occupation\u201d that he is qualified to do.\u201d<\/p>\n<p>Specifically, the Plan provides:<\/p>\n<p>\u201cDisabled or Disability means that, due to sickness or as a direct result of accidentally injury . . . You are unable to earn:<\/p>\n<ul>\n<li>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<\/li>\n<li>After such period, more than 60% 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.<\/li>\n<\/ul>\n<p>The Plan also contains a 12-month limitation on benefits for certain medical conditions. This 12-month limitation applies to disability due to <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/ltd-glossary-key-terms-in-policy\/mental-health-limitations\/\">mental or nervous disorders<\/a>, neuromuscular, musculoskeletal, or soft tissue disorders, <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/chronic-fatigue-syndrome\/\">chronic fatigue syndrome<\/a>, and related conditions. The most relevant of these conditions is the \u201cNeuromuscular, Musculoskeletal or Soft Tissue Disorder (the \u201cSoft Tissue Limitation\u201d), which the Plan further defines as follows:<\/p>\n<p>&#8220;Neuromuscular, musculoskeletal or soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of:<br \/>\n\u2013 Seropositive <a href=\"https:\/\/www.nickortizlaw.com\/practice-areas\/long-term-disability-insurance-erisa-lawyer\/medical-conditions\/arthritis\/\">Arthritis<\/a><br \/>\n\u2013 Spinal Tumors, malignancy, or Vascular Malformations<br \/>\n\u2013 Radiculopathies<br \/>\n\u2013 Myelopathies<br \/>\n\u2013 Traumatic Spinal Cord Necrosis; or<br \/>\n\u2013 Myopathies&#8221;<\/p>\n<p><strong>Benefits Paid? The plaintiff<\/strong>\u00a0was approved for long-term disability benefits on May 31, 20011, and received payment of back benefits as of February 10, 2011 (the date the Plan\u2019s elimination period ended). In March 2012, MetLife stopped paying benefits to Plaintiff without providing either notice or explanation.<\/p>\n<p><strong>Procedural history:\u00a0<\/strong>Plaintiff filed a claim under the Policy on February 24, 2011. MetLife approved Plaintiff\u2019s claim for long-term disability benefits on May 31, 2011. MetLife paid back benefits as of February 10, 2011, but abruptly stopped paying benefits to Plaintiff in March 2012. On April 17, 2012, Plaintiff wrote to MetLife complaining about the lack of benefits in accordance with MetLife\u2019s complete failure to explain the basis for its decision to stop paying Plaintiff benefits. The claim notes in MetLife\u2019s file show that MetLife was reevaluating the Plaintiff\u2019s claim in mid-February 2012.<\/p>\n<p>On May 7, 2012, MetLife sent a letter to Plaintiff stating that Plaintiff\u2019s claim was currently under investigation to decipher if the \u201cbenefits would continue beyond your [Plaintiff\u2019s] benefit under the plan\u2019s limited disability benefit provision.\u201d Additionally, MetLife stated that it would continue to pay benefits under a reservation of rights pending the investigation results.<\/p>\n<p>MetLife denied Plaintiff\u2019s claim on June 14, 2012, stating that Plaintiff\u2019s condition was within one of the 12-month limited conditions but failed to state which limiting condition it was. The plaintiff then sought counsel from Mr. George Kingsley, who submitted an appeal on the Plaintiff\u2019s behalf. On December 7, 2012, MetLife upheld its denial of Plaintiff\u2019s claim. The plaintiff responded by filing a lawsuit, which ultimately settled with the following conditions:<\/p>\n<ul>\n<li>\u00a0MetLife agreed to pay Plaintiff a certain sum in return for Plaintiff waiving his claim to any further benefits for the remaining <a href=\"https:\/\/www.nickortizlaw.com\/own-occupation-vs-any-occupation\/\">24-month \u201cown occupation\u201d period<\/a>.<\/li>\n<li>MetLife agreed to evaluate whether Plaintiff was entitled to benefits for the \u201cany occupation\u201d period, which began on February 11, 2013.<\/li>\n<li>The time requirements for claims handling regulations from the Department of Labor were expressly incorporated into the settlement agreement. Met Life was required to decide Plaintiff\u2019s claim \u201cnot later than 45 days after receipt of the claim by the plan.\u201d<\/li>\n<\/ul>\n<p>On August 8, 2014, Plaintiff submitted the documents he would rely on in making his claim under the \u201cany occupation\u201d provision of the Plan. Per the strict timing guidelines set out in the settlement agreement, MetLife had until September 22, 2014, to issue a decision regarding Plaintiff\u2019s claim. MetLife failed to meet the deadline, issuing a letter on September 24, 2014, stating that Plaintiff\u2019s file had been <a href=\"https:\/\/www.nickortizlaw.com\/peer-review-report\/\">submitted for a physician review<\/a>. However, Plaintiff\u2019s claim file was not submitted to a reviewing physician until December 12, 2014, after the current litigation began.<\/p>\n<p>On November 11, 2014, since MetLife had still not issued a decision nor had it provided Plaintiff with any explanation for the lack of the decision, Plaintiff again wrote MetLife in a \u201cgood faith effort to avoid litigation,\u201d as Plaintiff clearly stated that MetLife\u2019s decision was untimely under ERISA guidelines. When MetLife completely failed to respond to Plaintiff\u2019s letter, Plaintiff filed the present lawsuit on December 3, 2014. On December 23, 2014, MetLife gave Plaintiff a report from an MCN reviewer, Dr. Jon Glass. On February 24, 3016, MetLife denied the Plaintiff\u2019s claim, accompanied by an investigative report by Ethos Risk Services and several other documents. Plaintiff rejected the report MetLife submitted and responded with a March 16, 2016, letter by Dr. Shimizu. MetLife responded with a new medical report by Dr. Sims, which Plaintiff again rejected.<\/p>\n<p><strong>Issues:\u00a0<\/strong>The Court addressed the issue of MetLife\u2019s failure to issue a timely denial letter and the basis for its refusal to supply Plaintiff with a reason for its action in violation of ERISA. More specifically: \u201cMetLife\u2019s unexplained refusal to issue a denial letter until the eve of trial turned this case from a straightforward issue of whether [Plaintiff] was disabled under the Plain into a tangled accumulation of filings and counter-filings regarding matters that distract the Court from the merits of this case. For instance, the Court came to the trial facing fourteen filings with potential issues that required rulings.\u201d<\/p>\n<p><strong>Holdings:\u00a0<\/strong>The Court held that given MetLife\u2019s violations of ERISA, MetLife was ordered to pay Plaintiff current on his benefits and pay past-due benefits, with interest, to Plaintiff for the beginning of the <a href=\"https:\/\/www.nickortizlaw.com\/own-occupation-vs-any-occupation\/\">\u201cany occupation\u201d period<\/a> on February 11, 2013, to the present. The Court stated that for a claimant to know what evidence is relevant, they must know why the insured denied their claim. The Court cited ERISA, which specifically states: \u201cAn insurer making an \u2018adverse benefit decision\u2019 to provide a written denial identifying the specific reasons for the denial so the insured can address them during the claim appeal process.\u201d<\/p>\n<p>The Court held that MetLife undermined the ERISA process by failing to issue a proper denial and, further, by failing to notify the insured about the issues in dispute. \u201cRequiring that plan administrators provide a participant with specific reasons for denial enables the claimant to prepare adequately for any further administrative review as well as appeal to the federal courts. A contrary rule would allow claimants, who are entitled to sue once a claim has been \u201cdeemed denied,\u201d to be \u201csandbagged\u201d by a rationale the plan administrator adduces only after the suit has commenced.\u201d Harlick v. Blue Shield of Cal., 686 F.3d 699, 720 (9th Cir. 2012).<\/p>\n<p><strong>Summary:\u00a0<\/strong>The Court ordered MetLife to bring Plaintiff current on his benefits and pay past-due benefits, with interest, to Plaintiff from the beginning of the \u201cany occupation\u201d period on February 11, 2013, to the present. The Court remanded the case to MetLife for a determination that complies with ERISA of Plaintiff\u2019s benefits under the \u201cany occupation\u201d provision of the Plan. Additionally, the Court ordered MetLife to continue paying benefits so long as they continue to remain due under the provisions of the Plan, unless and until MetLife issues a denial that is in full compliance with the requirements contained in ERISA. In conclusion, the Court entered judgment in favor of Plaintiff.<\/p>\n<div class=\"content-box-blue\">\n<p>Disclaimer: This case was not 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.<\/p>\n<p>Here is a PDF copy of the decision: <a href=\"https:\/\/www.nickortizlaw.com\/wp-content\/uploads\/2020\/04\/Tash-v.-MetLife-C.D.-Cal.pdf\">Tash v. MetLife<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The Court held that MetLife undermined the ERISA process by failing to issue a proper denial and, further, by failing to notify the insured about the issues in dispute. The Court ordered MetLife to pay past-due benefits, with interest, and to continue paying benefits so long as they continue to remain due under the provisions of the Plan, unless and until MetLife issues a denial that is in full compliance with the requirements contained in ERISA.<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[258],"_links":{"self":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7398"}],"collection":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/comments?post=7398"}],"version-history":[{"count":0,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/posts\/7398\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/media?parent=7398"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/categories?post=7398"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nickortizlaw.com\/wp-json\/wp\/v2\/tags?post=7398"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}