A plan participant sued MetLife claiming an improper denial of his long-term disability benefits under ERISA. Participant Dionisio Santana-Díaz was a financial analyst at Shell Chemical and a participant in the company’s employee welfare benefit plan issued by Metropolitan Life Insurance Company (“MetLife”). Mr. Santana-Díaz suffered from major depression, high blood pressure, asthma and various other physical and mental conditions and stopped working. He received sick leave and then short-term disability benefits. After being out of work for five months, Mr. Santana-Díaz submitted his claim for long-term disability benefits and was eventually awarded LTD benefits. About a year and a […]

The U.S. District Court for the Northern District of Texas, on February 19, 2016, granted in part and denied in part Dewayne Curtis’ motion to compel discovery from MetLife. While discovery in ERISA actions is generally limited, in this case, the court required MetLife to answer some of Mr. Curtis’ questions in the form of interrogatories. The court required MetLife “to more fully describe the policy and methods used to determine compensation for the claims and appeals specialists who handled Plaintiff’s claim, such as any policy or method for determining and calculating bonuses, pay increases, or gain sharing.” However, MetLife […]

The United States District Court for the Eastern District of Kentucky on February 12, 2016 found Aetna arbitrarily and capriciously terminated Scott Bishop’s ERISA-governed long-term disability benefits. Mr. Bishop stopped working in February 2012 due to “diffuse osteoarthritis and swelling in his joints, gout, and degenerative joint disease in his left knee.” Based upon his physical conditions, Mr. Bishop applied for his Aetna LTD benefits and Social Security (“SSA”) disability benefits. Social Security had Mr. Bishop examined by Dr. David Winkle, who authored a report on Mr. Bishop’s condition. Aetna quickly determined Mr. Bishop was not entitled to LTD benefits. […]

Sobhani v. Reliance Standard Life Ins. Co. The Second Circuit, on December 18, 2015, affirmed the District Court of Connecticut’s summary judgment ruling in favor of Reliance Standard Life Insurance Company (“Reliance”) in Jeffrey Sobhani’s action for disability benefits under the Employee Retirement Income Security Act of 1974. In a brief Summary Order, the court quickly explained disability benefit determinations are reviewed under a de novo standard of review. Except “when, as in this case, written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, de novo review does not apply; rather, we will not disturb […]

In this month’s edition of the Missouri Physicians Health Program’s newsletter, Shelby Hendrix described The 10 Most Damaging Myths About Alcoholism: The Only Way to Get Better is to Hit “Rock Bottom” Drinking Culture is Harmless “You have a job, you’re not an alcoholic!” Willpower Alone Can Stop Addiction Controlled Drinking is Possible Everything will be Perfect Once You Stop Drinking Treatment is the Magic Cure Alcoholics Must go to AA Sobriety is Boring Getting Sober is Impossible To learn more about each of these myths, read the September 2015 Newsletter of the Missouri Physicians Health Program.

Melissa McKenna worked as an Administrative Assistant at Dow Corning Corporation where she received Long-Term Disability (LTD) group coverage provided by Aetna Life Insurance Company (Aetna). Ms. McKenna suffered from low back pain for many years, with a bulging disc first revealed in a 2010 MRI. Even with a bulging disc, Ms. McKinna continued to work until March 2012, when she was admitted to the hospital with a high pain level. Ms. McKinna was admitted again in April 2012 and began a treatment regimen with a pain management clinic, surgical injections, physical therapy, and treatment with a neurosurgeon, rheumatologist, physical […]

WHAT EFFECT WILL THIS HAVE ON MEDICAL PROVIDERS? Virginia Medicaid has announced it plans to abandon DSM-5 in October when the switch from ICD-9 to ICD-10 diagnostic coding takes place. Virginia is the first state to announce such a move. It will be interesting to see if this move causes other states to do the same, and the subsequent affect this has on all medical providers. Read more from Behavioral.net Related Articles BREAKING: Virginia Medicaid abandons DSM-5

The Ninth Circuit recently found the District Court for Northern California improperly reviewed MetLife’s denial of long-term disability benefits for plaintiff Matthew Prichard1. When a disability plan gives the plan administrator discretionary authority to determine a participant’s eligibility for disability benefits, a district court must review the administrator’s decision for abuse of discretion. Otherwise, the district court is required to review a plan administrator’s denial of benefits under the de novo standard of review. The de novo standard of review requires the court to look at the facts from the beginning, without giving any weight to the administrator’s determination. In […]

On March 25, 2015, in an unpublished opinion, the United States Court of Appeals, 6th Circuit, found that Michael Stiso was entitled to a cost of living adjustment with regards to his long-term disability benefit. Mr. Stiso had been receiving long-term disability benefits under his employer’s disability insurance plan and believed he was entitled to a seven percent per year cost-of-living adjustment as described in the long-term disability plan and summary plan description. The Sixth Circuit, in reversing the District Court’s ruling, stated By providing plaintiff with a summary plan description that led plaintiff reasonably to understand that he would […]

In a long running legal battle over an insureds long-term disability benefit, the full Sixth Circuit ruled last week that Daniel Rochow’s estate was not entitled to a disgorgement of profits in relation to benefits due on Mr. Rochow’s behalf. By way of background, Daniel Rochow filed a claim for long-term disability benefits in 2002 with his carrier, the Life Insurance Company of North America (“LINA”). LINA initially denied Mr. Rochow’s claim for disability benefits. Mr. Rochow proceeded to appeal and LINA proceeded to uphold their denial three more times. Finally, in 2004, Mr. Rochow filed suit in the United […]