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Darraslaw was able to get our client’s MetLife long term disability denial claim reversed.

The case involves a client who worked as an IT professional, a sedentary role requiring high focus and minimal stress, who developed severe mental health issues, including depression, anxiety, bipolar disorder, and suicidal ideation. These conditions rendered him unable to work, as confirmed by his psychiatrist and therapist, who placed him on suicide watch with family monitoring. His employer-provided group disability policy with MetLife, one of the largest group disability insurers, approved his short-term disability benefits for 26 weeks. However, when he applied for long-term disability benefits after the six-month elimination period, MetLife denied the claim, asserting he was no longer disabled and could return to work.

MetLife’s denial was based on a peer review by hired physicians (either in-house or external) who conducted a paper review of medical records, supplemented by surveillance. The peer review disagreed with the client’s psychiatrist, who reported severe depression, inability to leave the house, lack of focus, and suicide threats. The surveillance showed the client at a smoothie shop, which MetLife claimed indicated he was working and interacting with people, contradicting his reported anxiety and stress intolerance. In reality, the shop was his mother-in-law’s, and he was there under family supervision to prevent self-harm, not working. MetLife’s reviewers argued that his presence at the shop and interactions with customers proved he could handle a 40-hour-a-week IT job, a conclusion the attorneys deemed illogical and baseless.

Attorney Rachel Alters crafted a comprehensive appeal to reverse the denial, focusing on refuting MetLife’s misinterpretations and reinforcing the client’s disability. Key steps included:

• Collaborating closely with the client’s psychiatrist and therapist, who were outraged by the denial and provided detailed letters and customized attending physician statements outlining his severe mental health issues, inability to work, and ongoing suicide risk.
• Obtaining affidavits from the client’s mother-in-law and family, clarifying that he was not employed at the smoothie shop, received no paycheck, and was only there for supervision due to his mental state, directly countering MetLife’s surveillance claims.
• Submitting additional medical records to demonstrate that the client’s condition had not improved since the short-term disability approval, arguing that MetLife bore the burden of proving improvement, which they failed to do, as his condition had worsened.
• Challenging the peer review reports, highlighting their dismissal of the treating doctors’ opinions and the flawed logic equating casual interactions at a smoothie shop with the cognitive and stress demands of an IT role.

The appeal emphasized the subjective nature of mental health claims, which lack objective tests and rely on self-reported symptoms and clinical observations. Alters underscored the client’s frequent treatment—seeing a psychiatrist every two weeks and a therapist multiple times weekly—as evidence of severity, countering typical insurer arguments about insufficient treatment or lack of hospitalization. The passionate advocacy of the client’s doctors, who insisted he needed time to heal, was pivotal, as was the family’s documentation debunking the surveillance narrative.

MetLife reversed the denial based on the appeal’s compelling evidence, reinstating the client’s long-term disability benefits, which he has received for about six months. The attorneys noted that mental health claims, like depression and bipolar disorder, are inherently challenging due to their subjective basis, often leading insurers to question severity or demand more tangible proof. This victory highlights MetLife’s willingness to reconsider strong appeals, but the risk of future denials remains, especially given the high benefit amount and the typical 24-month limit on mental health claims. Alters continues to monitor the claim to prevent further denials, ensuring ongoing documentation of the client’s condition. The case offers hope for claimants with psychiatric disabilities, demonstrating that thorough appeals, supported by engaged doctors and clear refutations of insurer errors, can succeed in ERISA-governed claims.