Quite often, insurance companies create a maze of entities that could confuse the most cautious policy holders. One entity may own the fund. Another entity may administer the fund. So who should a plaintiff sue when these corporate entities conspire to break a promise to pay disability benefits? Fortunately, skilled disability lawyers know these insurance company tricks and can figure out who is ultimately responsible for a wrongful denial of disability benefits. Sometimes, it depends on bringing the right claim against the right party.
The case of Franklin v. AT&T Corporation is a prime example. The plaintiff worked at AT&T as a systems analyst for eleven years. She had long-term disability benefits under the AT&T Long Term Disability Plan for Management Employees ("the Plan") that were administered by Metropolitan Life Insurance 安徽福彩网app官方下载 ("MetLife’). Sedgwick Claims Management currently handles all AT&T disability claims. In 1999, the plaintiff filed for and received the long-term disability benefits arising from a number of causes including Crohn’s disease, breast cancer, chemotherapy, chills, night sweats, nausea and depression.
Three years later, MetLife reevaluated the plaintiff’s eligibility for long-term disability benefits. MetLife had demanded that the plaintiff apply for Social Security disability insurance benefits and, when she obtained them, reimburse the Plan for all the social security benefits she received when the Social Security Administration agreed she had been totally disabled since 1999. Soon after cashing the check, MetLife determined that the plaintiff was not in fact totally disabled and stated she could return to full-time work in other occupations. This conclusion led MetLife to deny the plaintiff’s claim for continued long-term disability benefits.
The plaintiff sued, arguing that her long-term disability benefits were wrongfully denied by MetLife and the Plan. Both defendants filed a number of motions. MetLife challenged the plaintiff’s ability to hold the insurance company accountable for its role in denying coverage because AT&T had fired MetLife as the plan administrator more than a year and a half before the plaintiff filed suit. The Plan claimed that the denial was within its discretionary authority.
The Court Awards Disability Benefits for What MetLife Did
A federal court in Dallas ruled that the plaintiff was entitled to long-term disability benefits and that MetLife was entitled to be dismissed from the lawsuit as it was merely the administrator. The plaintiff could only recover the disability benefits from the Plan because it had not brought a claim against MetLife for breach of the duty of good faith and fair dealing, which requires Texas insurance companies to treat policy holders in a certain manner. Nonetheless, MetLife’s actions were the central focus of why the court held the Plan responsible. The court specifically noted:
- MetLife had distorted the opinions of treating physicians when it characterized the plaintiff as able to return to full-time work;
- MetLife had not given adequate consideration to the determination for Social Security purposes that the plaintiff was totally disabled; and
- Though relying on the availability of leave under the Federal Medical Leave Act to claim that the plaintiff could be absent from work to accommodate her illness, MetLife failed to recognize that, as a new employee, the plaintiff was not eligible for leave under the FMLA for twelve months.
While MetLife wasn’t financially responsible to the plaintiff in this case, other companies may think twice before employing MetLife as a plan administrator in the future. The federal court held that MetLife had "cherry-picked" facts in the administrative file to support its position and, for this reason, MetLife had acted in an arbitrary and capricious manner. These wrongful actions persuaded the federal court to order the Plan to reinstate the plaintiff’s long-term disability benefits. Ironically, the plaintiff could have prevailed against MetLife as well (above and beyond the disability benefits recovered against the plan) had the plaintiff’s lawyer brought a claim for breach of the duty of good faith and fair dealing.
Franklin v. AT&T Corp., No.03:08-CV-1031-M, 2010 WL 669762 (N.D. Tex. Feb. 24, 2010)