The 9th Circuit recently decided the ERISA claim of Kathy Dine in Dine v. MetLife Insurance. The 9th Circuit reversed the district court's decision and agreed with Dine, stating that MetLife abused its discretion when denying her long term disability benefits.
The Court found it indisputable that MetLife, as the administrator of the plan, had a structural conflict of interest, because it "both evaluates claims for benefits and pays benefits claims." Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 112 (2008). While the existence of a conflict of interest is only one of the factors to consider, the Court found that “[a] higher degree of skepticism is appropriate where the administrator has a conflict of interest." Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 (9th Cir. 2011). The administrator has the burden of proving that the conflict of interest did not improperly influence its decision. See Muniz v. Amec Constr. Mgmt., Inc., 623 F.3d 1290, 1295 (9th Cir. 2010).
Finding that an administrator abused its discretion depends on the specific facts of the case. In this case, the Court found that MetLife abused its discretion for three reasons. First, the record indicated that MetLife notified Dine by letter that it was "presently reviewing [the] claim" and stated that if "additional information is needed to complete our review, we will notify you accordingly." However, MetLife then denied Dine's appeal, stating that she had submitted insufficient evidence. Second, MetLife's determination that Dine was not disabled contradicted the opinion of her treating physician. Third, MetLife ignored its own reviewing physician's advice to order an independent medical examination.
If your long term disability ERISA claim has been denied, speak to an experienced disability insurance attorney at Delfino Green and Green.
