employee benefits

By: Stephen A. Jackson

Hennen v. Metro. Life Ins. Co., 17-3080, 2018 WL 4376994 (7th Cir. Sept. 14, 2018).

Hennen worked as a sales specialist for NCR when she sought treatment for a back injury.  She was covered under her employer’s long-term disability plan insured by MetLife.  When physical therapy and surgery failed to resolve her injury Hennen applied for LTD benefits under the plan. Acting as the administrator, MetLife agreed Hennen was disabled and paid benefits for two years.  However, the plan had a two-year limit for neuromusculoskeletal disorders subject to several exceptions, one applies to radiculopathy.  Hennen argued she was entitled to benefits beyond the 2-year limitation because she has radiculopathy.

Hennen had a history of back problems with a surgery in 2003 and 2008 including fusing three vertebrae in her lower back.  In February 2012 she suffered a new back injury and sought treatment with a specialist in physical medicine and rehabilitation.  She was diagnosed with disc herniation and was treated with physical therapy and pain management techniques.  Failing conservative treatment an orthopedic surgeon recommended surgery and operated on Hennen’s L3-L4 disc herniation in September 2012.  At follow up appointments Hennen was struggling to sit for any extended period of time and she complained of bilateral radiating pain down the buttocks, posterior thighs, and to the knee.  An MRI was ordered that showed no nerve compression.

With no surgical option Hennen sought treatment from Dr. Buvanendran, an anesthesiologist who provided pain management.  The physician treated Hennen’s leg weakness and pain with a series of epidural injection.  He then diagnosed Hennen with post-laminectomy pain syndrome and lumbar radiculopathy.  The injections failed and so the anesthesiologist implanted a spinal cord stimulator.  It provided relief for a few weeks, but symptoms returned including recurrent leg weakness and tripping.  After the device was dislodged in a fall, Hennen had multiple surgeries to fix ongoing issues with it.

With the two-year limit on the horizon MetLife contacted Hennen’s doctors for information. Dr. Buvanendran responded that Hennen was unable to work due to post-laminectomy pain syndrome and radiculopathy.

MetLife then advised Hennen that her condition fell within the neuromusculoskeletal limit and that additional documentation was needed to support a diagnosis of radiculopathy.  Hennen had another MRI.   On October 13, 2014, MetLife wrote Hennen that her benefits were scheduled to end on November 11, 2014, under the neuromusculoskeletal limitation.  Dr. Buvanendran then faxed the MRI to MetLife, which showed a new annular fissure but no herniation or stenosis. MetLife’s reviewing physician opined the MRI did not show compression that would support a diagnosis of lumbar radiculopathy.

Hennen appealed and through help of counsel challenged MetLife’s conclusion.  She also submitted an EMG by Dr. Kipta, a neurologist.  Dr. Kipta found nerve-related abnormalities on the EMG and concluded it confirmed radiculopathy in four nerve roots as did an examination that showed diminished nerve sensation.  Another board-certified neurologist Dr. Malik, who supervised Dr. Kipta, agreed with his findings.

Dr. Adewumni, MetLife’s medical director reviewed Hennen’s appeal and agreed with Dr. Kipta that the EMG supported radiculopathy.  Concluding that Hennen satisfied the radiculopathy exception MetLife consulted with Dr. McPhee to assess her condition and asked him two questions, whether the medical file supported functional limitations and if so, what those limitations were. Despite the limited scope of these questions Dr. McPhee opined the EMG was negative for active radiculopathy with no abnormal activity recorded.  He also criticized Hennen’s self-reported pain levels as implausible and he found her doctor’s notes on muscle weakness inconsistent.

MetLife utilized Dr. McPhee’s assessment to reject the medical director’s conclusion and to decide that Hennen did not meet the exception for radiculopathy.  Dr. Buvanendran responded that the EMG confirmed radiculopathy without any doubt and that Hennen suffers from radiculopathy.  In response, Dr. McPhee prepared an addendum and opined it would be helpful for Hennen to have additional electrodiagnostic testing.  MetLife did not order an IME or additional testing as Dr. McPhee had recommended nor did MetLife explain why additional testing was unnecessary. Instead, MetLife upheld its decision the next day.

Hennen sued MetLife in the Northern District of Illinois seeking plan benefits under ERISA. Upon cross-motions the court granted summary judgment for MetLife, reasoning Hennen failed to offer evidence of active radiculopathy.  The court also found MetLife’s reliance on Dr. McPhee’s opinion was reasonable.

Upon appeal to the Seventh Circuit the court agreed that Hennen had shown MetLife’s decision to terminate benefits was arbitrary and capricious.  MetLife acted arbitrarily when it credited Dr. McPhee’s opinion over the opinions of four other doctors, including Hennen’s treating physician, two neurologists with clinical training in electrodiagnostic training, and MetLife’s own medical director. The arbitrary character is demonstrated by MetLife’s choice not to follow Dr. McPhee’s recommendation to order an IME and additional testing.

To reach the conclusion that that Hennen lacked “objective evidence” of active radiculopathy MetLife relied on Dr. McPhee’s opinion based solely on a file review without examining Hennen. MetLife acted arbitrarily in rejecting the opinions of every physician who examined Hennen who concluded she had radiculopathy. Those doctors’ opinions ad substantial medical support and Dr. McPhee was the only doctor who believed that radiculopathy was absent. But MetLife never asked McPhee to diagnose Hennen or make a finding of radiculopathy.  McPhee was only asked to assess Hennen’s functional limitations once Dr. Adewumni concluded Hennen met the plan’s radiculopathy exception.

Another indication of arbitrary decision-making was MetLife’s failure to heed Dr. McPhee’s recommendation to seek further testing and an IME.  MetLife chose not to follow up on Dr. McPhee’s advice and instead treated his original opinion as definitive and immediately sent Hennen a letter affirming the denial of benefits.

As a fiduciary, MetLife owed Hennen a duty to execute faithfully the terms of the plan. Here, MetLife took an extra step for its own benefit when it referred Hennen’s file to Dr. McPhee, but when Dr. McPhee recommend that MetLife take an extra step for Hennen’s benefit – to confirm whether his lone opinion was accurate – MetLife declined to take that step.  That was arbitrary and capricious.

The fact that MetLife acted arbitrarily and capriciously does not mean that Hennen is automatically entitled to benefits.  The remedy is to remand to MetLife, so it can reassess Hennen’s claim consistent with the court’s opinion and to correct the defective procedures and provide Hennen with the procedures she sought in the first place.

Related Articles

The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

Contact Bryant Legal Group

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

Request Your Free Consultation

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

This field is for validation purposes and should be left unchanged.

employee benefits

By: Andrew B. Bryant

On February 6, 2018, the Illinois Appellate Court issued a significant decision safeguarding healthcare benefits for injured public safety employees under the Illinois Public Safety Employee Benefits Act (“PSEBA”) (820 ILCS 320/1 et seq).

In the case, a City of Des Plaines Police Officer stopped a truck for operating with an apparently overweight load. At a local weigh station, the overweight violation was confirmed by the officer. The officer then climbed a ladder to inspect the truck’s load in order to complete administrative paperwork required by the City. While climbing the ladder, the officer injured his leg and was ultimately diagnosed with left medial and lateral meniscus tears in his left knee, ending his police career. The officer was awarded a line-of-duty disability pension, but his petition for healthcare benefits under the PSEBA was contested by the City. The City argued that although the officer suffered a qualifying “catastrophic” injury under the PSEBA, the activity that the officer was engaged in at the time of the injury was not a qualifying activity that warranted the award of healthcare benefits under the PSDEBA.

Under the PSEBA, healthcare benefits can be awarded to public safety employees when a qualifying injury occurs as a result of (1) response to fresh pursuit, (2) response to what is reasonably believed to be an emergency, (3) the unlawful act perpetrated by another, or (4) the investigation of a criminal act. The Court noted the officer was clearly not engaged in fresh pursuit or responding to an emergency, and the traffic code violation did not qualify as a “criminal act” under Illinois law. Therefore, the case turned on whether the officer was injured as a result of the truck driver’s unlawful act of hauling an overweight load. In affirming the trial court’s award of PSEBA healthcare benefits, the Appellate Court held that the officer was duty bound to take action in response to the truck driver’s violation of the law. Therefore, as the officer’s injury was indisputably a clear consequence and effect of the truck driver’s unlawful act of driving his truck in contravention of the Illinois Vehicle Code, the injury occurred because of an unlawful act perpetrated by another as set forth in the PSEBA.

See Marquardt v. City of Des Plaines (2018 IL App 1st 163186).

The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

Contact Bryant Legal Group

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

Request Your Free Consultation

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

This field is for validation purposes and should be left unchanged.

employee benefits

Long-term disability coverage is essentially the “private insurance” version of Social Security Disability Income (SSDI) in that it operates as a wage replacement for those who are rendered incapable of working for an extended period of time due to their disabling condition.  Long-term disability benefits are often offered through one’s employer, but it is not uncommon for such benefits to be obtained independently through an individual plan.

If you are making a long-term disability claim, you are likely suffering from a serious and debilitating condition, and as such, an insurer’s failure to grant long-term disability benefits can be particularly damaging from both a financial and emotional standpoint.  Disabled policyholders who can no longer work — and who have also had their claims denied by their insurer — may find themselves stuck in a difficult situation at the crossroads of insurer greed, incompetence and administrative issues.  When pursuing a long-term disability claim, it’s therefore vital that you work with a qualified Chicago long-term disability attorney who can provide the necessary assistance you need.

What Makes Long-Term Disability Coverage Unique?

Long-term disability benefits are rather simple to understand.  Unlike short-term disability benefits, long-term disability benefits are intended to provide an income for an extended period of time to those who have been rendered incapable of working due to their qualifying, disabling condition.  This income may be percentage-based (i.e., you receive 50 percent of your wages as long-term disability benefits), or may be a specific amount (i.e., you receive $3,000 per month per the language of the long-term disability policy) that is not actually related to your wages.  In any case, long-term disability benefits are paid out for a period of at least a year, and up to age 65, depending on the plan.

For example, one plan may offer higher benefits and have a very broad definition of “disability,” but last for only five years, while another plan may offer lower benefits and have a stricter definition of “disability,” but last until retirement age.

Long-term disability benefits are intended to last for a sufficiently long enough time to serve as adequate compensation for the wage loss of the claimant.  Given that the overall benefits payout tends to be higher than short-term disability benefits (due to the lengthier period of time during which benefits are paid out), you are more likely to encounter insurer roadblocks when making a claim for long-term disability benefits.

Complete Disability — Definitions May Vary

What constitutes a qualifying “complete disability” depends on your particular coverage.  As a general rule, however, a disability in the context of long-term disability benefits is any condition that renders you incapable of working at your current job — stricter definitions are occasionally encountered, so be sure to confirm the language of your policy with a qualified Chicago long-term disability attorney here at Bryant Legal Group, P.C., before making a claim for benefits.

Some long-term disability insurance plans have a list of automatically qualifying conditions.  For example, your insurance plan may include certain debilitating immune system conditions, such as Lupus.  If you qualify under one of the listed conditions, then it will be quite difficult for the insurer to justifiably challenge your claim for benefits.

Looking for Personalized Advice From an Insurance Lawyer?

Schedule a Free Consultation

Regular Updates Are Necessary

Each plan has a regular schedule for updates.  Further, benefits recipients are required to update the insurer whenever there has been a significant change in circumstances that may influence the long-term disability benefits at issue.  This is what is referred to as the insureds’ duty to provide continuing proof of loss. For example, if you have recovered from the disabling condition enough that you can return to your job, you will have to update the insurer so that they can terminate the benefits.  Failure to report could result in various penalties.  It is irrelevant whether your plan lasts for five years or until retirement age — if your condition is no longer disabling, then you cannot receive benefits.

Contact Us Today to Speak With an Experienced Chicago Long-Term Disability Attorney

If you have recently become disabled or are already suffering from a disabling condition and have had your long-term benefits claim denied by your insurer (whether the coverage is through your employer, or independent of your employer), it’s important that you consult with an experienced long-term disability attorney for guidance.  Your attorney can help you gather necessary evidence and repackage your application for benefits, challenge decisions made by the insurer through the appeals process, and potentially sue and recover damages on your behalf for wrongful denial.

Here at Bryant Legal Group, P.C., we have successfully advocated on behalf of disabled claimants for many years, helping policyholders obtain the long-term disability benefits to which they are entitled.  We understand that in the wake of a disabling condition, claimants are likely to feel overwhelmed and under pressure. To that end, we work closely with our clients and keep them updated on developments throughout the engagement process.

Call (312) 561-3010 today to speak with one of our long-term disability attorneys.  We look forward to assisting you.

The content provided here is for informational purposes only and should not be construed as legal advice on any subject.

Contact Bryant Legal Group

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

Request Your Free Consultation

Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.

This field is for validation purposes and should be left unchanged.