Metlife's wrongful denial of long-term disability benefits to a Wells Fargo employee is reversed
Many employees rely on disability insurance benefits if they have been injured or have developed a sickness which prevents them from working. Disability insurance provides individuals with a percentage of his or her typical salary until the employee is able to return to work or turns age 65. However, what employees aren’t usually aware of is that as soon as disability benefits start, the disability insurance company wants them to stop – and they will use a wide range of tactics to make that happen.
As an attorney who has worked on thousands of long-term disability claims against major insurance companies around the country, I can tell you that insurance company tactics can involve undercover investigations, fact-twisting, and even having bias doctors subjectively determine that you are not disabled as in a recent disability insurance case.
Graciella Saffon vs. Wells Fargo
Graciella Saffon, an employee of Wells Fargo Bank, had suffered from degeneration of her cervical spine for several years. This condition was confirmed by several MRIs, X-rays and other medical information. In 2001, Saffon was in a car accident which aggravated her neck condition, leading her to quit her desk job and apply for long-term disability benefits with MetLife. After a certain amount of time, the insurance company began paying Saffon long-term disability. However, a year after she began receiving these long-term benefits, MetLife stopped paying them, informing her that she no longer met the terms of disability.
How MetLife Worked to Deny Mrs. Saffon Her Long-Term Disability Benefits
MetLife hired two different doctors to look over Saffon’s medical records, resulting in the following statements.
The first physician, Dr. Thomas, stated that “Saffon’s file lacks clear sequential, detailed and objective clinical information, which would completely preclude Ms. Saffon from an attempt to return to work.”
After Dr. Thomas’s file review, MetLife stopped the long-term benefit payments. Saffon appealed MetLife’s denial and provided an updated cervical MRI with additional medical records. A letter from her neurologist, Dr. Kudrow, was also included, stating that she had undergone various pain treatments which were ‘without sustainable benefit’ and that she was unable to remain in a sitting position for more than a few minutes at a time.
Following the submission of the Appeal, a second doctor, Dr. Menotti, looked over Saffon’s records and claimed that her reports of headaches and chronic pain syndrome were not enough to keep her from working. MetLife then stated that Saffon had not supplied them with a functional capability evaluation so they were unaware of her ability to function at work. The appeal was denied.
Mrs. Saffon sued MetLife in California District Court, seeking back-payment of her disability income benefits. The District Court affirmed MetLife’s denial, and Mrs. Saffon continued her battle for disability benefits by filing an appeal with the 9th Circuit Court of Appeals. After reviewing the case, Judge Kozinski determined that MetLife had not given Saffon’s case a full and fair review for the following reasons:
- “Its [MetLife] communications with Saffon and her doctors are hardly a model of clarity; they certainly do not explain ‘in a manner calculated to be understood by the claimant’ what Saffon must do to perfect her claim.” According to an earlier case, Booton vs. Lockheed Medical Benefit Plan, the insurance company must clearly communicate to the policyholder why their claim is being denied and what they must do in order to perfect it. Judge Kozinski was not convinced that this had happened in Mrs. Saffon’s case.
- Information in Mrs. Saffon’s medical records was ignored or not considered fairly.
- MetLife’s complaint that they were not provided with a functional capability evaluation was not followed by a chance for Mrs. Saffon to provide that information to them.
Judge Kozinski remanded the case back to the California District court, requiring that they give a full and fair look at Mrs. Saffon’s case taking into account the flaws in their review process and the ERISA laws. This was a victory for Ms. Saffon, who was given a second chance to show that she most certainly did deserve disability benefits due to her inability to work. However, one has to note that Mrs. Saffon did everything she could to show this in the first place, and had MetLife acted reasonably, Mrs. Saffon would not have had to go without her disability benefits or go through a painful and drawn out battle in court at all.
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MetLife Reviews
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They FULL OF ****
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MetLife for disability? Avoid the surgery unless it's life-threatening
The worst company I ever dealt with, never received a call from my claim manager.
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Only care about $$$$$
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They demanded an overpayment, stopped my claim, and lied about it
Metlife over paid me. Stopped my Ltd claim. The overpayment were not done right. They lied and said they deposited money in my account.
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MetLife
Your decision making process is absurd!
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Inappropriate conduct!! Rude, discriminatory, etc
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Answered Questions by Our Lawyers
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A: Jim:If this payment is a form of a retirement or pension payment then it is likely correct for Metlife to of... Read More >
Q: Do I have an option after my appeal is denied?
A: Lauren:If your appeal is denied by MetLife then you have the option to file lawsuit in federal court. Read More >
Q: My daughter died in 2019
A: If your daughter was disabled prior to being terminated then she should have coverage. Read More >
Q: Can I sue Metlife for non payment of approved claim?
A: Unfortunately, the answer is "not liklely." I would assume your MetLife policy is an employer provided policy ... Read More >
Q: How far behind in payments does Metlife have to be to take legal action?
A: Make sure you put all of your requests in writing so there is a record should you end up in court. It’s best... Read More >
Q: Does Metlife pay Disability payments ahead? Example: December payment is for January.
A: Peg, most disability insurers pay monthly disability benefits in arrears, in other words, payments are made fo... Read More >
Q: Would any new disabling conditions be considered by Metlife when considering whether or not to continue my benefits?
A: The change in diagnosis will likely lead to denial so please explain the situation to your treating doctor. Me... Read More >
Q: MetLife: Mental Health and Physical Disabilities
A: If you have physical disabilities that prevent you from working then you have options to get around the mental... Read More >
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Our attorneys have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement in more than 98% of our cases. Our disability insurance lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.
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