Our law firm gets ready against Metropolitan Life

As our law firm gets ready for a federal court hearing on a disability insurance case this week, I am reminded about just how difficult it is to collect on a private disability insurance policy.

In this case, against Metropolitan Life, the insurance was provided by the employer, Verizon. In many cases, employers pay all or part of the insurance premium. And, where the insurance is an employee benefit, a federal law called ERISA applies.

Disability insurance is typically paid to an individual who cannot perform the duties of their job, or in some cases, cannot perform the duties of any job. The insurance benefits are paid monthly, typically at 60, 80 or 100% of the person’s salary.

Obviously, an insurance company has a huge financial incentive to deny claims. And, if they deny a claim, what is the legal recourse? Typically, a disability plan will provide for an “appeal.” And, to whom is that appeal submitted? Answer: the appeal goes to the insurance company and its internal review board. This is a classic example of the rooster guarding the hen house.

If the insurance company believes it is a close case, or a case they want to deny, they often will hire an “independent” doctor who they pay handsomely, to review the records. There is rarely a doubt whose side the “independent” doctor will favor.

In a case of very serious disabilities such as total blindness, loss of all limbs, severe brain damage, the insurance company will pay without a fight. But, in closer cases like psychiatric diagnoses, severe shoulder or back pain, it is much more difficult to collect. Further, the courts often require objective findings to recover. So, if you are totally disabled due to unbearable pain or psychiatric illness, there may be little or no objective evidence.

If the objective evidence does not get the insured claimant, then there are other ways to lose. The courts allow the insurance company to exercise their discretion and the courts defer to the insurance companies. As long as there is “substantial evidence” in the file to support the insurance company (e.g., their “independent” doctor’s report), the insured automatically loses the court case.

So, tomorrow, I get to go into US District Court against Met Life , and argue that my client with a psychiatric illness should be allowed to collect disability insurance because her doctor has said she is too disabled to work. Of course, her treating doctor’s opinion won’t carry much weight, since the insurance company doctor said there is no objective evidence that she can’t work.

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Bruce Coane is a leading lawyer with 30 years of experience in the field of immigration law and employment law. He may be reached via email at houstonlaw@aol.com or his website at Coane and Associates.