Mark M. (MetLife)
Mark was a Chartered Property Casualty Underwriter (CPCU) and an Associate in Reinsurance (A.Re). He had a 20-plus year background in commercial casualty claims and a 15-plus year background in reinsurance.
Mark was an Assistance Vice President for a large reinsurance management, audit and consulting company. His occupation was fast-paced and involved high stress, requiring both physical and mental strength. He was required to work very long hours, typically in excess of 12 hours per day. His occupation also involved frequent domestic and international air travel to conduct reinsurance audits. He would often fly to audit locations on Sundays, so as to put in a full workday on Mondays. This usually involved packing for trips on the Saturdays before, and then booking the latest return flight on Friday nights to get back home. On occasion, he would have "back-to-back'" audits, involving non-stop audits for two weeks at a stretch. He was highly successful, earing in excess of $150,000 in 2003, when he became disabled.
He suffered Type II Diabetes on top of severe problems with neck pain, An MRI confirmed substantial deficits, including bulging discs; nerve root sleeve compression; and cervical arthritis. Eventually, he could no longer work.
Mark’s LTD Policy provided a very high grade of coverage, which was to pay benefits to age 65, so long as he is disabled from his "Own Occupation for any employer in (his) Local Economy ". "Local Economy" is defined as meaning "the geographic area surrounding your place of residence, which offers reasonable employment opportunities. It is an area within which it would not be unreasonable for you to travel to secure employment. . . . "
After paying his Short Term Disability benefits for a period of 90 days, MetLife denied his LTD claim on the stated ground that “no objective findings documented . . . Based on the medical information contained in your file, there are no clinical findings that correlate with a severe psychiatric or physical functional impairment to support your inability to perform your occupation.”
No hint was given as to what "objective findings" MetLife needed. An MRI report clearly showed paracentral disk protrusions C5-6 and C6-7, compression of the left nerve root sleeve and flattening of the cervical cord at C5-6, and bilateral moderate foraminal stenosis at C5-6 and C6-7. Also, Mark 's blood tests remained dangerously abnormal and his subjective symptoms were consistent with the diagnosis of Diabetes Mellitus Type II. The restrictions and limitations occasioned by those symptoms were clearly disabling, given the demands of his high-stress occupation.
I submitted an administrative appeal, which addressed the grounds for denial, specifically calling attention to the many "objective" clinical findings supporting the claim. Thereafter, MetLife paid 2 months LTD benefits and then, incredibly, it upheld denial of all remaining benefits on the stated ground that: "We have not been provided with medical information that would support a disabling condition . . . Therefore, we find that the original claim determination was appropriate and his benefits . . . will remain denied". The letter further stated that all administrative remedies were exhausted and that "no further appeals will be considered."
After receipt of the final letter, additional medical information was provided to Metlife, which showed that Mark s condition had grown even worse. This information consisted of a further examination reports by the treating physician; an Electrocardiogram report; a Cardiolite Stress Test; an Echocardiogram report; and several blood test reports.
The following month Mark was awarded Social Security Disability (SSDI) benefits. A copy of the award letter and written opinion of the Administrative Law Judge were forwarded to Metlife, along with a detailed letter, explaining the relevance of the SSDI decision.
After receipt of all this information, Metlife issued a letter, which cryptically stated, "We have reviewed the additional information submitted and have determined that this information would not change our decision to terminate (Mark’s) claim." No further explanation was given for MetLife's denial of benefits.
It was later determined that one of MetLife’s own reviewing doctors, had opined that “based on the diabetes alone the claimant would be considered medically unable to perform the essential duties of his own occupation”.
Result: The case was resolved satisfactorily.