Opinion ID: 151538
Heading Depth: 3
Heading Rank: 3

Heading: Mitchell's Claims for LTD Benefits with MetLife

Text: On April 15, 2004, Mitchell applied for LTD benefits by completing and submitting a long-term disability claim request form with MetLife. In Section 2: Claim Information, the request form includes three boxes to be completed concerning the onset of disability. The first box asks for the Date of first treatment for this condition; Mitchell supplied 10/2003. The second box seeks Date last worked MUST ANSWER; Mitchell answered still working. The third box asks for Date Disability Began; Mitchell responded 10/2003. On April 23, 2004, MetLife denied Mitchell's claim on the ground that he was ineligible for benefits because he did not meet the definition of disability or disabled under the Certificate of Insurance definition because he was capable of performing his work as VP of Sales, which is classified as sedentary. It based this conclusion on the Attending Physician's Statement, which indicated that Mitchell received treatment for osteoarthritis of the knee and that Mitchell was working now. The denial was also explicitly based on Mitchell's statement on the claim form that he was still working. The letter also advised Mitchell of his right to appeal this adverse determination. Mitchell then availed himself of MetLife's administrative review process as outlined in the April 23, 2004 letter. In December 2004, he filed an appeal and submitted additional medical records, supporting letters from examining physicians, and colleagues at CB Richard Ellis. On January 18, 2005, MetLife upheld its original decision to deny LTD benefits to Mitchell, this time finding that he did not meet its summary plan definition of disability. Under this definition, a plan participant must be unable to perform the material and substantial duties of his/her regular occupation. MetLife further stated that an independent physician's review of the medical documentation did not support a finding that Mitchell's condition was severe enough to prevent him from performing his own occupation, and concluded that Mitchell did not meet the summary plan definition of disability. During the initial claim and the administrative review processes, MetLife never specified as a reason for denial that it was not the provider of LTD benefits at the claimed onset of Mitchell's disability in October 2003.