MetLife denies long term disability benefits to sears store manager with heart disease and knee problems (Part I)

A long term disability insurance ERISA lawsuit filed against MetLife filed in U.S. District Court’s Northern District of Alabama, highlights once again the fact that you cannot depend on a disability plan to do what’s best for you. This case shows yet again that disability insurance companies aren’t above trying to skew the facts so they can discontinue short-term and long-term disability benefits while maintaining an appearance of doing so using a reasoned and careful process.

Having an appearance of making a logical decision is very important when a disability insurance plan gives the plan administrator the power to determine who qualifies for disability benefits as well as interpret what the language of the disability plan means. The Courts treat insurance companies deferentially when they have this right, which may seem counter-intuitive, but congress determined that this was the best way to keep litigation under control when it passed the Employee Retirement Income Security Act in 1974.

As we look at the history behind this lawsuit against Metropolitan Life Insurance Co. (MetLife), it may help other disabled individuals realize the importance of speaking with an attorney that specializes in disability insurance claims. Hiring a disability insurance attorney made a difference for Frank Blankenship.

Administration of long-term disability plan is MetLife responsibility.

The long-term disability plan that Blankenship participated in was offered to Sears, Roebuck and Co. employees. MetLife had the contract with Sears to both administer the plan and fund the plan as well. This was a typical change of definition disability plan. During the first 24 months of disability, Blankenship would become eligible for disability benefits if he was unable to fulfill the duties of his “own occupation” and as a result was also unable to earn more than 80% of his predisability earnings. After 24 months of disability, Blankenship would only remain eligible for long-term disability benefits if his disability was so severe that he could no work in any occupation for which he was reasonably qualified and could not earn more than 60% of his pre-disability earnings. The Plan also stipulated that if Blankenship received “other income benefits” such as Social Security disability income (SSDI), MetLife would reduce his benefits accordingly.

All was fine for the Sears store manager until he was diagnosed in May 2003 with coronary artery disease. Tests found that one coronary artery was 99% blocked, and two others were blocked 10% and 30%. As stent was inserted into the artery that was 99% blocked on May 9, 2003. Unfortunately, this failed to prevent a heart attack on August 23, 2003. Several physicians participated in monitoring his recovery – Dr. Frank Rudeseal, his primary care physician, and three cardiologists, Drs. Michael McKinney, Michael Honan, and Paschal Redding.

MetLife approves short-term disability benefits.

MetLife approved short-term disability benefits to cover his recovery. This coverage expired in January 2004, leading Blankenship to apply for long-term disability benefits. With his application for long term disability benefits, he included reports from both Dr. Rudeseal and Dr. Redding. Both doctors reported that Blankenship could not return to work because he could not tolerate stress and long hours. Dr. Redding added that both exercise and stressful situations brought on angina attacks.

MetLife denies extension of disability benefits.

Despite the fact that MetLife recognized that managing a large Sears store was a stressful occupation, it denied Blankenship’s application on February 17, 2004. The denial letter offered no explanation for the disability insurance company’s decision. Yet, in the background MetLife was still reviewing Blankenship’s application, for there was an entry in MetLife’s Diary Review Report dated March 5, 2004. The entry stated that Blankenship could not “work due to angina with stressful situations and exercise, … is limited due to the severity of his cardiac condition,” and that MetLife “would refer to” Social Security, indicating MetLife anticipated Social Security finding Blankenship disabled and the expectation that the long-term disability benefits MetLife would have to pay out would be off-set by his SSDI benefits.

MetLife approves disability benefits, even though records remain the same.

A March 10 entry indicated that MetLife was well aware of Blankenship’s “significant cardiac history” and noted that it was unlikely that he would return to work. The next day, MetLife reversed its decision to deny long-term disability benefits and approved Blankenship’s application for long-term disability benefits, making the payments retroactive to January 12, 2004 under the Plan’s “own occupation” terms.

MetLife reverses decision based on lack of “medical evidence.”

Blankenship applied for SSDI on June 14 as required by MetLife in order to prevent his disability benefits from being reduced by the amount MetLife estimated he would receive if his application with Social Security was approved. This application was denied on October 7, 2004. MetLife then informed him on December 22, 2004 that it was terminating his benefits based on the records available. MetLife told Blankenship in its letter that “there is no objective medical [evidence] on file to support a disability.” The letter failed to mention that the Social Security denial was also one of the pieces of evidence influencing the decision.

Once again, Blankenship provided letters from Drs. Redding and Rudeseal. Both physicians continued to state their opinions that the stress related to a management position made it impossible for Blankenship to work. Dr. Redding claimed he was “approaching 100% disability because of his inability to function … in stressful situations.”

MetLife sent Blankenship’s file to an “independent” internist and cardiologist, Dr. Mark J. Friedman. He concluded without conducting a physical examination that Blankenship suffered only moderate coronary artery disease and should be able to perform light work duties. MetLife used these findings to deny Blankenship’s appeal on February 11, 2005.

MetLife finds knee surgery reason to restore disability benefits.

Ten days later, Blankenship had to have knee surgery to repair a tear in his left knee that had occurred three weeks before. MetLife reinstated his LTD benefits on April 1 under the “own occupation” standard. The decision was based on the knee surgery and the expected time it would take for rehabilitation.

MetLife then notified Blankenship on July 29, 2005 that he would only be able to continue receiving disability benefits if as of January 12, 2006, he could demonstrate that he was disabled from “any occupation.” Even though MetLife claimed to have approved Blankenship’s disability benefits based on his knee surgery, the disability insurance company continued to ask his doctors for information about his heart condition.

Dr. Rudeseal responded to MetLife’s July 29, 2005 request for information by reiterating his opinion that Blankenship was permanently disabled because his heart condition made it impossible for him to handle stress. Dr. Michael Honan, another cardiologist that was treating Blankenship, responded to a MetLife letter also sent on July 29 with the same conclusion. Blankenship’s condition was permanent and that any gainful employment was impossible due to coronary symptoms “precipitated by stressful situations.”

MetLife also sent part of Blankenship’s information to an “independent” vocational rehabilitation consultant in its employ. The only information the consultant looked as was the report from Blankenship’s orthopedic surgeon. Nothing about Blankenship’s heart condition was included, so it was only natural that the report MetLife received on December 9, 2005 did not take this health issue into consideration. The consultant had identified three occupations, all stressful, which only considered Blankenship’s potential work restrictions for knee problems. The report demonstrated that Blankenship would be able to earn more than 60% of what he had made as a Sears Manager. His ability to handle stress was not considered in these conclusions.

MetLife terminates disability benefits a third time.

MetLife wrote an elaborate letter on January 5, 2006 informing Blankenship that his long-term disability benefits would be terminated on January 12. He appealed this decision. His file was sent to cardiologist, Dr. Michael Rosenberg, who also only read Blankenship’s file instead of performing a medical examination. Dr. Rosenberg responded to a list of specific questions, which the Court would later find seemed very carefully worded. He concluded that Blankenship could do “sedentary, light or medium work.” Conspicuously missing from the questions Dr. Rosenberg was asked was any evaluation on what relationship stress in the workplace might have on his condition.

MetLife also sent Blankenship’s file to an orthopedic surgeon. When the reviews from both physicians came back, MetLife chose to uphold its decision to deny long-term disability benefits under the “own occupation” provision of the Plan. The final denial letter sent on August 18, 2006 made it clear that Blankenship’s appeals were exhausted.

Social Security finds claimant is disabled after all.

Blankenship didn’t file action at that time, but after Social Security reversed its decision in July 2007, Blankenship began to reconsider. He received a lump-sum settlement for past-due benefits of $84,021.50. The SSDI decision considered both Blankenship’s coronary artery disease and the degenerative joint disease in his knees when it reversed its decision. While MetLife had the right to demand that Blankenship reimburse MetLife for its share of the retroactive benefits, the disability insurance company did not file a counterclaim until Blankenship decided to file a lawsuit against MetLife for wrongful termination of benefits.

Disability insurance attorney files suit to secure client’s disability benefits.

Blankenship hired a disability insurance attorney who regularly handled ERISA disability litigation. He would be representing Blankenship against MetLife’s experienced disability attorneys. Both sides filed motions requesting the Court to issue judgment “as a matter of law.” Which side would win the day in Court? That will be discussed in Part II of this article: Over $500,000 of disability insurance benefits will be paid to disabled store manager following MetLife’s wrongful denial.