A California federal court of appeals found that Metropolitan Life Insurance Company (“MetLife”) improperly terminated long-term disability benefits to a Wells Fargo Bank employee with cervical spine degeneration.
Ms. Graciela Saffon’s Disability and Claim
Ms. Saffon’s disability claim stemmed from a long history of degeneration of her cervical spine, a condition confirmed by repeated MRI scans and X-Rays. After a car crash aggravated her condition, she was forced to quit her desk job at Wells Fargo Bank and submit a claim for disability benefits under her long term disability policy with MetLife.
MetLife initially approved long-term disability (“LTD”) benefits, but eventually terminated payments based on its consulting physician’s opinion that Ms. Saffon did not provide objective evidence of disability.
Ms. Saffon then submitted an appeal with additional evidence of disability, including her most recent MRI and another letter from her treating neurologist, who confirmed she was still unable to tolerate sitting for an extended period.
MetLife denied Ms. Saffon’s appeal relying on one medical records review completed by its consulting physician. In its final denial letter, MetLife (for the first time) relied on the fact that Ms. Saffon did not provide a Functional Capacity Evaluation to support her claim. Following the denial of her appeal, Ms. Saffon filed a lawsuit in federal court against MetLife. When the lower Federal District Court denied Ms. Saffon any relief, she appealed that decision to the federal Court of Appeals.
The Court’s Decision
The Court of Appeals disagreed with the lower court’s ruling, finding MetLife made several critical mistakes in its claim review process. Specifically, the Court found:
- MetLife did not meet its duty to have a “meaningful dialogue” with Ms. Saffon as it failed to explain what information she needed to submit to perfect her claim or why the evidence she already submitted (including an MRI showing degenerative changes) was not enough.
- MetLife’s claim in its final denial letter that Ms. Saffon should have submitted a Functional Capacity Evaluation came too late to do her any good. MetLife cannot tack on a new reason for denying benefits in its final decision.
- It was improper for MetLife to communicate directly with Ms. Saffon’s doctors without advising her of the communication.
The Court’s decision is significant as it sets very clear guidelines for the disability claims process, allowing claimants a fair chance to present evidence and preventing insurance companies from turning their review into a game of “gotcha.”
Disability Insurance Companies Have Lawyers. Shouldn’t You?
Because this law firm was created to focus on disability insurance, we have developed an expertise in this complex area of the law.
Our expertise in long-term disability claims means our clients have the backing of a law firm that has attorneys who:
- are experts in disability claims;
- fought all major disability insurance companies and know their tactics;
- a track record of success;
- won major disability lawsuits that created good law; and
- recovered millions of dollars in disability benefits.
All our lawyers commit every day of their legal career to helping people get disability benefits from MetLife, UNUM, Prudential, Northwestern Mutual, Hartford, CIGNA, and others.
Because federal law applies to most disability insurance claims, we do not have to be located in your state to help. We help clients nationwide.
Call to get experienced disability lawyers on your side with:
- Submitting a disability insurance claim;
- Appealing a long-term disability denial;
- Negotiating a lump-sum settlement; and/or
- Filing a lawsuit against your disability insurance company.
Call for a free consultation with a disability attorney.
