We represented our client in his appeal against MetLife’s termination of disability insurance benefits for injuries he suffered after a car accident. Our goal: MetLife reverses termination decision. MetLife claimed that his diagnosis falls under one of the limiting disabilities which would end his benefits after 24 months.
The plan specifically states that if a person is disabled due to neuromuscular, musculoskeletal or soft tissue disorder the disability benefits would be limited to 24 months. However, if there is objective evidence of one of the seven enumerated exceptions listed in the plan, then the limitation does not apply. Our client’s medical records show that although he does suffer from one of the limiting disabilities, he also falls under the exception to that rule. MetLife still terminated his benefits after 24 months, citing the limitation rule.
We filed an appeal letter and included all his medical evidence that showed he was disabled and he met the exception to the limitation rule. Included in the medical evidence was a Pain and Physical Capacity Questionnaire filled out by his treating physician. The questionnaire stated his physical condition is so limiting he could not reliably work an 8 hour work day. The doctor stated that the combination of pain and medication causes lapses in concentration on a regular basis. Ultimately, the questionnaire concluded that he is unable to work in any capacity.
Additionally, we provided progress notes from another one of our clients doctors which repeatedly cites “lumbar radiculopathy” among his diagnoses. This diagnosis is one of the seven enumerated conditions that would fall under the exception to the limitation rule MetLife relied upon in terminating his benefits.
MetLife Reverses Termination – The medical evidence was very clear. Our client was permanently disabled and fell under the exception to the limitation rule. Shortly after our appeal was filed, MetLife sent a letter indicating they have reversed the termination and reinstated our clients’ disability insurance benefits.
Because each client’s case is unique and has different facts, results similar to those in other clients’ cases are not guaranteed.
