Legal Summary: Walsh v. Metropolitan Life Insurance

Walsh v. Metropolitan Life Insurance.
3:06-1099, 2009 WL 603003 (M.D. Tenn. March 9, 2009)

Our client worked as a sales representative until October 2002 when he had to stop working due to his disabling medical condition.  Walsh v. Metropolitan Life Ins. Co., 2009 WL 603003 at *1 (M.D. Tenn. March 9, 2009).  He applied for and was awarded long-term disability benefits beginning March 8, 2003.  Id. at *2.  During the first two years of benefits, the plaintiff only had to be disabled from his own occupation, but after the first two years of benefits, the plaintiff had to be disabled from any occupation to continue receiving benefits.  Id. at *1.

In September 2004, MetLife, the insurance company, notified our client that it was reviewing his eligibility for continued long-term disability benefits under the plan’s “any occupation” definition of disability.  Id. at *3.  MetLife requested updated documentation from the plaintiff’s treating physician, Dr. Standard.  Id.  After receiving the updated records from Dr. Standard, MetLife followed up with him but received no response.  Id.  A doctor hired by MetLife then reviewed plaintiff’s file and issued a report stating that plaintiff could do sedentary work.  Id.

By letter dated March 9, 2005, MetLife notified plaintiff that his disability benefits were being terminated, effective March 7, 2005.  Id.  Furthermore, this letter told the plaintiff that he had 60 days to respond and request a review of his claim in writing.  Id.  Without hiring an attorney, the plaintiff responded by letter dated May 16, 2005.  Id.  Again, via letter, in July 2005, MetLife affirmed its decision to terminate the plaintiff’s long-term disability benefits and told the plaintiff that the decision to terminate his benefits was final and would not be reconsidered.  Id. at *3.

The plaintiff hired us in December 2005, and we helped him obtain updated medical information, including a new opinion form from his doctor and a sworn statement from his doctor.  We pointed out that under a recent update to ERISA regulations, MetLife should have allowed him 180 days to appeal, not 60.  MetLife refused to consider the new information and reaffirmed its position that the previous decision was a final denial. Id, at 4.

We sued MetLife under ERISA, arguing that when MetLife’s decision should be overturned because MetLife told our client his appeal had to be filed within 60 days, rather than 180 days, as required by ERISA.

In court, MetLife argued that the 60-day appeal time frame was permissible because the insurance company “substantially complied” with the purposes of ERISA as outlined in Kent v. United of Omaha Insurance Company, 96 F. 3d 803 (6th Cir. 1996).  Walsh, 2009 WL 603003, at *5.  Kent established that a technical failure to comply with ERISA’s procedural requirements could be excused if the purposes of ERISA were satisfied.  Id.  The court did not agree with this argument.  Id. at *6.

Rather, the court agreed with us that the purposes of ERISA’s 180-day rule were not met by the insurance company.  Id. at *6.  The purposes of ERISA’s 180-day rule: to give a claimant the specific reasons for termination of benefits, to provide an opportunity for a full and fair review of the claim, and to insure that a claimant had sufficient time to consider and prepare an appeal.  Id. at *6 (citing Wenner v. Sun Life Assur. Co. of Canada, 482 F.3d 878, 882 (6th Cir. 2007); PENSION AND WELFARE BENEFITS ADMINISTRATION, 63 Fed.Reg. 48390, 48393 (Sept. 9, 1998)).  The ERISA claims regulations applied here and directly stated that when an adverse benefit determination occurred, the claimant would have “at least 180 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination…”  Id. at *5 (citing 29 C.F.R. § 2560.503-1(h)(3)(i)).

The court agreed with us that MetLife’s error in giving our client only 60 days to appeal caused substantive harm to his claim because he rushed to appeal the denial pro se, without supporting documentation.  Id. at *6.  The court rejected MetLife’s argument that the insurance company would have accepted additional documentation within 120 days after the initial appeal time of 60 days, because MetLife had told our client that his appeal was final and that no further materials would be considered at the administrative level.  Id. 

Our client, before he hired us, had “no reasonable way of knowing his rights had been violated and that he had an additional 120 days in which to supplement his appeal.”  Id.  The court agreed with us that, when MetLife instructed the plaintiff that an appeal of his benefits termination was to be filed within 60 days, rather than 180 days, as required by ERISA, MetLife was in error.  Id. at *6.  The court then ordered the case remanded to MetLife to properly consider the claim.