Court Orders Long Term Disability Insurance Benefits to be Reinstated for Lupus Sufferer

Partner, Glenn Kantor recently won a case against Metropolitan Life Insurance and the Colgate-Palmolive Welfare Benefit Plan.

Our client, Ms. Bledsoe is a 39 year old woman who was employed by Colgate-Palmolive Company. In August 2009, she was forced to stop working because she was unable to perform her duties due to systemic lupus erythematosus which caused severe fatigue, headaches, arthritis, arthralgia, inflammatory rash and chest pain. She initiated a Short Term Disability (“STD”) claim for benefits Metropolitan Life Insurance (“MetLife”), lasting 6 months. At the conclusion of those 6 months, MetLife approved Ms. Bledsoe’s Long Term Disability (“LTD”) claim after a MetLife Nurse stated that Ms. Lupus was disabled.

In December 2011, Ms. Bledsoe’s treating physician submitted a physician statement which outlined that Ms. Bledsoe was expecting improvement by the end of 2011 or early 2012.

On February 2012, MetLife terminated Ms. Bledsoe’s benefits. She appealed the termination and her doctor submitted evidence showing that she had headaches, severe fatigue and joint pain that lasted all day. MetLife reinstated benefits after their own doctors found that Ms. Bledsoe was disabled.

On August 2012, Ms. Bledsoe returned to work. After less than three months however, she was admitted to the emergency room and ordered by her physician to stop full time work due to recurrent symptoms of Lupus. Her doctor submitted a letter to MetLife requesting that she be placed on long term disability for at least one year. He reported in his statement that work had proved to exacerbate her symptoms.

MetLife advised Ms. Bledsoe that she had not established a basis for a recurrent disability, on the basis that the medical file did not support that she was unable to work due to a flare up of her lupus condition. Ms. Bledsoe appealed this decision and her treating physicians submitted 506 supporting documents to MetLife including a list of her side effects from taking the medications for her lupus. These side effects included dizziness, insomnia, headaches, weakness, swelling of hands and feet, nausea and vomiting. She was also ordered to rest every hour for 15-30 minute, making her unable to perform the duties of any occupation given her age, education and training.

MetLife denied Ms. Bledsoe’s appeal again.

Ms. Bledsoe filed suit in the United States District Court in the Central District of California.

After trial, the Court ruled in favor of our client, and discussed three significant issues.

First, the court held that MetLife’s prior finding of Ms. Bledsoe as disabled, was significant. The court found that the medical record clearly demonstrated Ms. Bledsoe’s disability and as a result, MetLife provided STD and LTD for nearly three years. The court therefore stated that it would expect MetLife to provide some evidence of Ms. Bledsoe’s medical progression at the time of MetLife’s termination of LTD benefits. It further added that while MetlLife did not need to prove a material improvement in Ms. Bledsoe’s condition to defeat her entitlement, her lack of consistent, marked progress was probative of her continuing disability.

Second, the court held that Ms. Bledsoe was disabled under the terms of the plan at the time of the denial of benefits. MetLife made several arguments including citing a professional baseball player and former President as examples of individuals able to function with a medical condition. The court stated that it did not view the mere diagnosis of lupus as a disability that requires LTD benefits. Rather it was the extent of the symptoms associated with lupus that rendered one disabled. The court held that MetLife could not ignore the fact that Ms. Bledsoe had both the condition and the associated symptoms because MetLife determined she was disabled in 2009 due to this very medical condition.

The court also questioned whether due consideration was given to Ms. Bledsoe’s overall medical history. It found that MetLife’s Physician, Dr. Marwah reviewed Ms. Bledsoe’s medical records but he did not examine her in-person. Instead his conclusion was based on a 10 minute conversation with Ms. Bledsoe’s treating physician.

Finally, the court held that Ms. Bledsoe could not work in an occupation for which she qualified. MetLife argued that no evidence indicated Ms. Bledsoe could not perform another occupation, specifically a sedentary occupation. The court however, held that Ms. Bledsoe could not perform either the essential duties of her own occupation or the essential duties of any occupation for which she was reasonably qualified, taking into account her training, education, and experience.

This was a welcome result for Ms. Bledsoe, and an important victory for all people struggling to get their Long Term Disability insurance claims paid!

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