It is no secret that disability insurance companies will often seek out the same medical consultants that they have used hundreds of times before to perform “independent” medical reviews of disability claims. This would not pose a problem if the medical consultants (i.e., physician, nurse, therapist) were fair, unbiased and not affected by the huge financial rewards which come with maintaining a steady stream of business flowing from a client that is a multi-billion dollar insurance company.

Often, when these medical consultants are asked to review a claim to determine what restrictions and limitations, if any, the insured has, or if based on the medical records the insured could return to work, these hired guns, without so much as even glimpsing at a picture of the claimant, will determine that the insured has no restrictions or limitations that would prevent them from working. Not only will the medical consultants make unfounded and unreasonable conclusions, but sometimes, they will even take issue and attempt to undermine the medical treatment prescribed by the insured’s own treating physicians!

MetLife Pays Short-Term Disability Claim But Denies Long-Term Disability Claim After Claimant’s Employer Terminates Him Due to His Physical Inability to Do Job

A California operations technician was forced to file a disability claim with Metropolitan Life Insurance Company (MetLife) due to a back injury aggravated at work. In August 2007, Mr. Rowles was employed with Air Products and Chemicals, Inc., when he slipped and fell at work and re-aggravated a back condition. Due to the resulting pain and discomfort, Mr. Rowles’ physicians believed it was necessary for him to take time off of work to rest and heal his back. Mr. Rowles submitted a claim for short-term disability benefits with MetLife, which MetLife reviewed and paid until Rowles returned to work a month later. Mr. Rowles attempted to work for 4.5 days before he was again forced to stop work due to his back pain. A few days later, he received a telephone call from his employer advising him that he was being terminated because it felt that he could no longer physically do his job. Shortly thereafter, Mr. Rowles submitted a claim for long-term disability benefits. Four months later MetLife denied Mr. Rowles’ long-term disability claim stating that it did not have evidence that he was disabled after he stopped working and that he did not meet the waiting period in the plan. Mr. Rowles timely appealed MetLife’s denial only to be denied again 3 weeks later.

MetLife Hires Orthopedic Surgeon, Who It Had Previously Paid Over $250,000 to Conduct Over 418 Disability Reviews, to Conduct “Independent Medical Review” and Find That There Are No Functional Limitations

Discouraged, but thinking that perhaps new reports from his treating physicians would convince MetLife that he was indeed disabled, Mr. Rowles decided to submit a final appeal for disability benefits. The reports from Mr. Rowles’ treating physicians provided noteworthy evidence of the difficulties he was having dressing himself, getting on and off the toilet, and that his physical pain had lead to psychological distress with emotional and cognitive symptoms.

Instead of overturning its decision to deny benefits, MetLife hired Dr. Howard P. Taylor, an orthopedic surgeon, who had spent prior years working for The Paul Revere Life Insurance Company and Unum Life Insurance Company of American as an in-house medical consultant evaluating disability claims, to perform an “independent medical review” of Mr. Rowles’ disability claim. It was also discovered that Dr. Taylor had been paid over $250,000 by MetLife over a three year period to conduct 418 “independent medical reviews.” Unfortunately for Mr. Rowles his fate was sealed as soon as MetLife decided to hire Dr. Taylor. Without ever physically examining Mr. Rowles, and only reviewing the medical records, Dr. Taylor determined that, since Mr. Rowles attempted to return to work for 4.5 days, he would not be considered to have functional limitations that would include any reduction in his ability to work full time. Based on Dr. Taylor’s findings, MetLife advised Mr. Rowles that it was upholding its prior decision and that he had exhausted all of his administrative remedies.

Federal Court Finds That MetLife’s Reliance on Its Bias Independent Medical Physician Was Wrongful and Violated ERISA

Following receipt of the final denial letter from MetLife, Mr. Rowles filed suit against MetLife in California federal court, seeking the only thing that he could under ERISA, payment of his disability insurance benefits. In a firmly worded opinion, US District Court Judge Consuelo B. Marshall, found on behalf of Mr. Rowles, stating, “[t]his Court has a definite and firm conviction that a mistake has been committed in denying Mr. Rowles benefits.” MetLife was found to not only have wrongfully denied Mr. Rowles disability benefits, but it also violated ERISA when: 1) MetLife placed greater weight on Dr. Taylor’s opinion, when Dr. Taylor was the only doctor out of many to find Mr. Rowles was able to work; 2) MetLife and Dr. Taylor dismissed the conservative treatment prescribed by Mr. Rowles’ treating physicians and suggested that it was inappropriate, when it had no legal authority or supporting expert opinion for its findings; and 3) MetLife and Dr. Taylor emphasized the fact that Mr. Rowles went back to work for 4.5 days and deduced from this that he was able to work.

5 Years After A Metlife Disability Denial, Claimant Gets Paid his LTD Benefits

Fortunately, Mr. Rowles was paid his disability benefits. However, it took nearly 5 years and a no nonsense federal judge for that to happen. MetLife’s actions in the Rowles case and the hiring of bias “independent” physicians, like Dr. Taylor, are not exclusive or unique to MetLife. The truth is these are actions taken by different disability insurance companies every single day. It is a misconception that disability insurance companies will only bother paying big fees to physicians like Dr. Taylor in claims involving large monthly disability benefits. Disability insurance companies do not discriminate based on occupation or benefit amount and will hire medical consultants and pay exorbitant fees to deny even the smallest claims. They will even use the same doctors time and time again because they know they will get consistent results and will be able to state that they have a medical basis to deny disability benefits, even when that basis is unfounded. However, as proven here, the only way an insured can protect themselves against disability insurance company doctors like Dr. Taylor is to make sure that their medical support is strong and that their physician is unwavering, cooperative and thorough.

Although our firm did not handle this case, we handle have handled thousands that are similar throughout the country. We always offer a free consultation to discuss your disability claim.