Tough case. Wouldn’t any insurance company benefit from denying claims? If she is still disabled, then how could they pull her off the roll? If she’s not, then why wouldn’t they pull her off?
I think the problem is that many insurance companies have employees working in their claims departments who are uneducated regrading the role of the insurance company as fiduciary of the disability policy.
Without an understanding of the fiduciary role, the claim department employees render decisions that could lead to a claimant feeling forced to sue in order to obtain benefits.
It’s a shame.
What kind of definition of disability would Met have that would allow them to deny benefits as the client “had improved” yet the client would still qualify for Social Security.
The issue most likely is own occupation vs. any occupation. While she may not be able to do certain types of work related to her previous job, Met Life probably determined that thier was sedentary type jobs she could perform. Each disability claim stands on its own merits.
Whether they decide and pay or not. This article does not give enough detail. There are a lot of people out there working the system and getting benefits they do not deserve which costs all of us. In this case not enough details are given why she was denied further payments. We would all like to be paid not to work but somebody has to. I think her doctor should be the one who decides if she can work, not her insurance company. However, doctors can easily be bought so there needs to be a review process through a panel of other doctors to when necessary over rule the primary.
Hey, I’m all for that! Been going to my doctor for twenty years, lives in the same neighborhood, kids went to school with mine….I would trust him to certify that I was disabled (joking, of course).
The facts that are cited (probably not all of them, of course) don’t look too good for the insurer. Maybe this case could have been resolved far short of raising this issue.
It is common that SS benefits are awarded as the SS standard of disability is often much lower than the standard of proof and defintion required by private insurers.
I agree that is probably the definition change from her own occupation to any occupation which she is qualified to perform – this can mean a sedentary job such as secretary work even if she was disabled from doing patient lifting, for example.
Most claim people are educated and are genuinely concerned about doing the right thing – Met’s denial rate has been consistently below industry average.
Yeah, right. The doctors should decide – then the battle moves to “which doctors” or “whose doctors”?
There is a cottage industry of doctors that do nothing but testify for “injured parties”. They don’t have to practice medicine; they just write reports and bill hefty fees which are gladly paid by plaintiff lawyers…
JMHO
Just to clarify: my comment from earlier (re: fiduciary duty) was more of a general oberservation on the issue of discretion, versus regarding a specific company or specific claim situation.
I’m so much more at ease now that the Bush Administration has weighed in with their opinion.
By the simpleton standard, doesn’t everyone have a conflict of interest in denying their own money to others who want it? I guess this is the standard the feds use to raise me taxes, we’ll sure I don’t want to pay more, but I can’t make that decision, as I have a conflict of interest in wanting to keep my money for me, as that betters my condition? Maybe we should just let the government decide…anytime I see any administration weighing in with an ‘opinion’ I grab my wallet.
This definitely gives the impression that MetLife is learning somemthing from UNUM, who has been playing hanky panky with disability claim denials and stonewalling for years. Their claims managers and staff are rewarded with bonuses for reaching $$ threshholds in denials.
This was reported at:461 F.3d 660. The disease was “severe dilated cardiomyopathy.” This is a disease of the heart muscle that causes the heart to become enlarged and, for that reason, to pump inadequately. Plaintiff, who worked as a sales manager in a women’s clothing department, began receiving LTD benefits after it was determined that she could not perform the duties of her regular job as a result of severe dilated cardiomyopathy. The administrator terminated the benefits on the ground that plaintiff’s condition had improved to the point that she was no longer “totally disabled.” The court, however, concluded that the administrator’s determination could not be sustained because it was not the product of a principled and deliberative reasoning process. The administrator acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, the administrator offered no explanation for crediting a brief form filled out by plaintiff’s treating physician while overlooking his detailed reports. Moreover, there was no adequate basis for the administrator’s decision not to factor in the major consideration of the role that stress played in aggravating plaintiff’s condition. Taken together, these factors reflected an arbitrary and capricious decision.
Reading the comments is quite interesting. The issue is difficult and polarizing. I am a claims person and thus I may be biased. I think that I am balanced. Just because a premium has been paid there is no guarantee that the insured claimant will be truthful, candid or forthcoming. And, it would be axiomatic that an irritating claimant would not get the same quality or level of concern and service as one who was cooperative. Still, the issue becomes a medical issue. I am willing to bet heavily that Met has a medical opinion from a highly respected medical practitioner. On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. The claimant knows but it is not in her best interest to share the truth. And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.
I look forward with a great deal of interest in the Court’s ruling.
here’s another factor in the case: if they say improved – are they stating that she can work if so where? if so, are they planning to retrain? problem is that the disability insurance is based on the ability to complete the job she was doing or starting. the insurance has to get a medical statement that states she can continue the work she was doing prior to the disability. if not, the company could save themselves money (not the insurance company) by offering her a job, where she can continue to work for the company. all companies want to make a profit. its just a matter of where do we draw the line. there are many folks i believe that live on disability but yet can be retrained to work and be beneficial to society. many of those folks would rather sit for free money for the gov’t. this is a great way for them to earn and give back to the community. this would help the economy. now there are those who are not able to work anymore, but there are many who can.
Apparently MetLife did not even give the full medical reports to the experts they relied on in their denial — only a brief portion that supported the denial. The Sixth Circuit said. “MetLife’s decision to deny long-term benefits in this case was not the product of a principled and deliberative reasoning process. MetLife acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, it offered no explanation for crediting a brief form filled out by Dr. Patel while overlooking his detailed reports. This inappropriately selective consideration of Glenn’s medical record was compounded by the fact that the occupational skills analyst and the independent medical consultant were apparently not provided with full information from Dr. Patel on which to base their conclusions.”
SS ‘threshold of disability’ is extremely high. 99.9% of claimants are denied the first time. They must go to court and provide mountains of paperwork to prove that they are unable to work in any field. Not just the field they are trained in. There also has to be proof that there is no chance of recovery.
I know three people that actually went through the process. It takes two- three years (paid retroactively if you win), and then the attorneys get a chunk of what you do get.
So if this woman can prove that her illness is never going to improve (with that specific illness even walking 10 feet or climbing 5 stairs could be an issue) and she would risk heart failure (which is a symptom of the disease) by attempting to work sufficiently to the Fed Gov’t, it is understandable that Metlife was out of line in deciding on their own that she was ‘better’.
The insuring agreement containing the definition of disability should be the basis on which to grant or deny a claim. Then the facts about the injury or disease and extent thereof should support decision based on the definition of disability. If in fact, her condition had changed for the better, and she was able to resume work, she should not be entitled to the money. I think we are getting too much into an entitlement mentality in this country. If not, then continue benefits. What’s the problem?
If we let doctors decide they’ll decide on weekly “heat treatments” and “massage therapy” indefinitely, not all doctors are honest, they’re subject to human nature & greed too, they have a conflict of interest too.
What’s needed is precise contracts with precise definitions and reliable contract enforcement.
I was a worker’s comp investigator, 90% of the cases I workered were fraud or their injuries & abilites were wildly exaggerated.
Lets face it humans lie when its in their best interest and there’s no penalty and right now there’s no penalty for lying or exagerating your injuries.
“”There is a cottage industry of doctors that do nothing but testify for “injured parties”. They don’t have to practice medicine; they just write reports and bill hefty fees which are gladly paid by plaintiff lawyers… “”
And on that same thought.
There is also a cottage industry of doctors that do nothing but testify for “Insurer’s”. They just write reports and bill hefty fees which are gladly paid by Insurers…
“”On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. [[The claimant knows but it is *not* in her best interest to share the truth.]] And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.””
…It would appear that *Yes* you are biased.
Your assumption appears to be that everyone is lying because the Truth would expose a Fraud.
What if the Truth is that she is truly disabled. And she is telling the truth because the Truth *is* in her best interest.
Or should see lie and say she’s fine?? That way you could believe her.
I agree that insurer’s should hold to the contract regardless of the situation. If in fact the claimant was still unable to perform the material duties of her job and had the applicable % loss of income she would not have been taken off claim. The Social Security eligibility is another issue entirely. The contract could have been off set by other income such as Social Security or had a definition requiring that the claim be denied due to eligibility for Social Security. Of course the insurer would help her to do this. I don’t think there’s any finger to magically point in any one direction here. Now the supreme courts get to decide; what is their expertise again?
In 1999 MetLife discontinued my disability benefits after I had received a confirmation of total disability from Social Security at the age of 59. I could not afford my mortgage, so was forced to sell my home near all my children while I pursued legal action against MetLife. I was awarded an out of court settlement of 199K, but more than half was paid to attorneys representing me. Also, in order to receive my award, I had to sign a waiver against any other pursuit against MetLife in this regard. I am no longer able to afford to live in the area near my children, but have moved to an area where I can afford to live. I am still devastated that I lost so much of my life during this process.
I admitted to a bias. But I do not admit to a prejudice. Anyone who doubts that there are many claimants trying to get their “lottery” payment from Insurance companies, is so naive as to be dangerous. Have you watched the commercials for any of the “TV Lawyers”? Guess who helps those claimants who want to expand their claim or perpetrate fraud.
I can’t say that I agree or disagree with Met Life in this instance, or any of the others so far adduced, because I don’t know enough about the evidence in the case. I can say, Donna, I really feel for you. You have had a terrible ordeal. I’m sorry to hear that your lawyers took most of the award, but I am not surprised.
Smitty, I agree that saying there is 90% fraud in any claim situation is probably an exaggeration. I would suggest that maybe what is meant that is that there is exaggeration 90% of the time.
It seems to me if you use the logic that the 6th Circuit is using, any insurance company (health, life, disability, home or whatever) has a conflict of interest when it comes to paying a claim and should not have the authority to adjudicate claims. That seems a bit stupid to me.
Using the same logic, P&C insurers are conflicted every time they make a claim decision on one of their insureds. Let the facts support the ruling – don’t assume insurers are the bad guy – that’s why claims satisfaction surveys are done. People can buy their insurance from whomever they wish.
Insurers do not adjudicate claims. They investigate claims and work with insureds and claimants to settle claims. Settlement generally involves accord and satisfaction. Without that there is no settlement. Without settlement there is no resolution.
It is interesting that this case is about “Conflict of Interest” and the people weighing in are on either side of the fence or they would not have searched out this board. I am biased and I know it. very few posts on this board stick to facts, most are biased propaganda. Look at Bob’s post, it sure looks like facts. Those facts are at issue with this case and it appears Metlife was “arbitrary and capricious”. Seems Metlife “found” a way to deny the claim by pouring over medical reords to cherry pick what they could use to deny the claim. Before angst is thrown back at me, read all the briefs and court documents as I have and it appears Bob did. The Supreme Court tacked on more than Metlife wanted because they seem to have been waiting for a case like this to filter up.
Tough case. Wouldn’t any insurance company benefit from denying claims? If she is still disabled, then how could they pull her off the roll? If she’s not, then why wouldn’t they pull her off?
I think the problem is that many insurance companies have employees working in their claims departments who are uneducated regrading the role of the insurance company as fiduciary of the disability policy.
Without an understanding of the fiduciary role, the claim department employees render decisions that could lead to a claimant feeling forced to sue in order to obtain benefits.
It’s a shame.
What kind of definition of disability would Met have that would allow them to deny benefits as the client “had improved” yet the client would still qualify for Social Security.
The issue most likely is own occupation vs. any occupation. While she may not be able to do certain types of work related to her previous job, Met Life probably determined that thier was sedentary type jobs she could perform. Each disability claim stands on its own merits.
Whether they decide and pay or not. This article does not give enough detail. There are a lot of people out there working the system and getting benefits they do not deserve which costs all of us. In this case not enough details are given why she was denied further payments. We would all like to be paid not to work but somebody has to. I think her doctor should be the one who decides if she can work, not her insurance company. However, doctors can easily be bought so there needs to be a review process through a panel of other doctors to when necessary over rule the primary.
Hey, I’m all for that! Been going to my doctor for twenty years, lives in the same neighborhood, kids went to school with mine….I would trust him to certify that I was disabled (joking, of course).
The facts that are cited (probably not all of them, of course) don’t look too good for the insurer. Maybe this case could have been resolved far short of raising this issue.
It is common that SS benefits are awarded as the SS standard of disability is often much lower than the standard of proof and defintion required by private insurers.
I agree that is probably the definition change from her own occupation to any occupation which she is qualified to perform – this can mean a sedentary job such as secretary work even if she was disabled from doing patient lifting, for example.
Most claim people are educated and are genuinely concerned about doing the right thing – Met’s denial rate has been consistently below industry average.
Yeah, right. The doctors should decide – then the battle moves to “which doctors” or “whose doctors”?
There is a cottage industry of doctors that do nothing but testify for “injured parties”. They don’t have to practice medicine; they just write reports and bill hefty fees which are gladly paid by plaintiff lawyers…
JMHO
I absolutely agree.
Just to clarify: my comment from earlier (re: fiduciary duty) was more of a general oberservation on the issue of discretion, versus regarding a specific company or specific claim situation.
Thank you.
I’m so much more at ease now that the Bush Administration has weighed in with their opinion.
By the simpleton standard, doesn’t everyone have a conflict of interest in denying their own money to others who want it? I guess this is the standard the feds use to raise me taxes, we’ll sure I don’t want to pay more, but I can’t make that decision, as I have a conflict of interest in wanting to keep my money for me, as that betters my condition? Maybe we should just let the government decide…anytime I see any administration weighing in with an ‘opinion’ I grab my wallet.
Would love to know what injury was suffered…
This definitely gives the impression that MetLife is learning somemthing from UNUM, who has been playing hanky panky with disability claim denials and stonewalling for years. Their claims managers and staff are rewarded with bonuses for reaching $$ threshholds in denials.
This was reported at:461 F.3d 660. The disease was “severe dilated cardiomyopathy.” This is a disease of the heart muscle that causes the heart to become enlarged and, for that reason, to pump inadequately. Plaintiff, who worked as a sales manager in a women’s clothing department, began receiving LTD benefits after it was determined that she could not perform the duties of her regular job as a result of severe dilated cardiomyopathy. The administrator terminated the benefits on the ground that plaintiff’s condition had improved to the point that she was no longer “totally disabled.” The court, however, concluded that the administrator’s determination could not be sustained because it was not the product of a principled and deliberative reasoning process. The administrator acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, the administrator offered no explanation for crediting a brief form filled out by plaintiff’s treating physician while overlooking his detailed reports. Moreover, there was no adequate basis for the administrator’s decision not to factor in the major consideration of the role that stress played in aggravating plaintiff’s condition. Taken together, these factors reflected an arbitrary and capricious decision.
Reading the comments is quite interesting. The issue is difficult and polarizing. I am a claims person and thus I may be biased. I think that I am balanced. Just because a premium has been paid there is no guarantee that the insured claimant will be truthful, candid or forthcoming. And, it would be axiomatic that an irritating claimant would not get the same quality or level of concern and service as one who was cooperative. Still, the issue becomes a medical issue. I am willing to bet heavily that Met has a medical opinion from a highly respected medical practitioner. On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. The claimant knows but it is not in her best interest to share the truth. And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.
I look forward with a great deal of interest in the Court’s ruling.
here’s another factor in the case: if they say improved – are they stating that she can work if so where? if so, are they planning to retrain? problem is that the disability insurance is based on the ability to complete the job she was doing or starting. the insurance has to get a medical statement that states she can continue the work she was doing prior to the disability. if not, the company could save themselves money (not the insurance company) by offering her a job, where she can continue to work for the company. all companies want to make a profit. its just a matter of where do we draw the line. there are many folks i believe that live on disability but yet can be retrained to work and be beneficial to society. many of those folks would rather sit for free money for the gov’t. this is a great way for them to earn and give back to the community. this would help the economy. now there are those who are not able to work anymore, but there are many who can.
Apparently MetLife did not even give the full medical reports to the experts they relied on in their denial — only a brief portion that supported the denial. The Sixth Circuit said. “MetLife’s decision to deny long-term benefits in this case was not the product of a principled and deliberative reasoning process. MetLife acted under a conflict of interest and also in unacknowledged conflict with the determination of disability by the Social Security Administration. In denying benefits, it offered no explanation for crediting a brief form filled out by Dr. Patel while overlooking his detailed reports. This inappropriately selective consideration of Glenn’s medical record was compounded by the fact that the occupational skills analyst and the independent medical consultant were apparently not provided with full information from Dr. Patel on which to base their conclusions.”
SS ‘threshold of disability’ is extremely high. 99.9% of claimants are denied the first time. They must go to court and provide mountains of paperwork to prove that they are unable to work in any field. Not just the field they are trained in. There also has to be proof that there is no chance of recovery.
I know three people that actually went through the process. It takes two- three years (paid retroactively if you win), and then the attorneys get a chunk of what you do get.
So if this woman can prove that her illness is never going to improve (with that specific illness even walking 10 feet or climbing 5 stairs could be an issue) and she would risk heart failure (which is a symptom of the disease) by attempting to work sufficiently to the Fed Gov’t, it is understandable that Metlife was out of line in deciding on their own that she was ‘better’.
The insuring agreement containing the definition of disability should be the basis on which to grant or deny a claim. Then the facts about the injury or disease and extent thereof should support decision based on the definition of disability. If in fact, her condition had changed for the better, and she was able to resume work, she should not be entitled to the money. I think we are getting too much into an entitlement mentality in this country. If not, then continue benefits. What’s the problem?
so does that matter based on medical decisions? and whose doctor is correct? her’s or the insurance company? or do we have to get an arbitrator?
Lou is absolutely right. Now we get to wait to see if the supremes agree
If we let doctors decide they’ll decide on weekly “heat treatments” and “massage therapy” indefinitely, not all doctors are honest, they’re subject to human nature & greed too, they have a conflict of interest too.
What’s needed is precise contracts with precise definitions and reliable contract enforcement.
I was a worker’s comp investigator, 90% of the cases I workered were fraud or their injuries & abilites were wildly exaggerated.
Lets face it humans lie when its in their best interest and there’s no penalty and right now there’s no penalty for lying or exagerating your injuries.
Hey Wes,
“”There is a cottage industry of doctors that do nothing but testify for “injured parties”. They don’t have to practice medicine; they just write reports and bill hefty fees which are gladly paid by plaintiff lawyers… “”
And on that same thought.
There is also a cottage industry of doctors that do nothing but testify for “Insurer’s”. They just write reports and bill hefty fees which are gladly paid by Insurers…
Fred,
.
.
.
Well Jon,
Based on part of your comment… (brackets added)
“”On the other hand the claimant has medical providers who are saying that she is disabled. What is the truth? Not likely to ever know. [[The claimant knows but it is *not* in her best interest to share the truth.]] And, isn’t that the tragedy of litigation in this arena—it is not in the best interest of a party for the truth to be known.””
…It would appear that *Yes* you are biased.
Your assumption appears to be that everyone is lying because the Truth would expose a Fraud.
What if the Truth is that she is truly disabled. And she is telling the truth because the Truth *is* in her best interest.
Or should see lie and say she’s fine?? That way you could believe her.
Fred,
I agree that insurer’s should hold to the contract regardless of the situation. If in fact the claimant was still unable to perform the material duties of her job and had the applicable % loss of income she would not have been taken off claim. The Social Security eligibility is another issue entirely. The contract could have been off set by other income such as Social Security or had a definition requiring that the claim be denied due to eligibility for Social Security. Of course the insurer would help her to do this. I don’t think there’s any finger to magically point in any one direction here. Now the supreme courts get to decide; what is their expertise again?
Smitty,
90 % fruad…come on that has to be an exaggeration.
In 1999 MetLife discontinued my disability benefits after I had received a confirmation of total disability from Social Security at the age of 59. I could not afford my mortgage, so was forced to sell my home near all my children while I pursued legal action against MetLife. I was awarded an out of court settlement of 199K, but more than half was paid to attorneys representing me. Also, in order to receive my award, I had to sign a waiver against any other pursuit against MetLife in this regard. I am no longer able to afford to live in the area near my children, but have moved to an area where I can afford to live. I am still devastated that I lost so much of my life during this process.
I admitted to a bias. But I do not admit to a prejudice. Anyone who doubts that there are many claimants trying to get their “lottery” payment from Insurance companies, is so naive as to be dangerous. Have you watched the commercials for any of the “TV Lawyers”? Guess who helps those claimants who want to expand their claim or perpetrate fraud.
I can’t say that I agree or disagree with Met Life in this instance, or any of the others so far adduced, because I don’t know enough about the evidence in the case. I can say, Donna, I really feel for you. You have had a terrible ordeal. I’m sorry to hear that your lawyers took most of the award, but I am not surprised.
Smitty, I agree that saying there is 90% fraud in any claim situation is probably an exaggeration. I would suggest that maybe what is meant that is that there is exaggeration 90% of the time.
It seems to me if you use the logic that the 6th Circuit is using, any insurance company (health, life, disability, home or whatever) has a conflict of interest when it comes to paying a claim and should not have the authority to adjudicate claims. That seems a bit stupid to me.
Using the same logic, P&C insurers are conflicted every time they make a claim decision on one of their insureds. Let the facts support the ruling – don’t assume insurers are the bad guy – that’s why claims satisfaction surveys are done. People can buy their insurance from whomever they wish.
Insurers do not adjudicate claims. They investigate claims and work with insureds and claimants to settle claims. Settlement generally involves accord and satisfaction. Without that there is no settlement. Without settlement there is no resolution.
It is interesting that this case is about “Conflict of Interest” and the people weighing in are on either side of the fence or they would not have searched out this board. I am biased and I know it. very few posts on this board stick to facts, most are biased propaganda. Look at Bob’s post, it sure looks like facts. Those facts are at issue with this case and it appears Metlife was “arbitrary and capricious”. Seems Metlife “found” a way to deny the claim by pouring over medical reords to cherry pick what they could use to deny the claim. Before angst is thrown back at me, read all the briefs and court documents as I have and it appears Bob did. The Supreme Court tacked on more than Metlife wanted because they seem to have been waiting for a case like this to filter up.