MetLife Subjective Condition Exclusion

In Warden v. Metropolitan Life Ins. Co., 574 F.Supp.2d 838 (Tenn.M.D. August 26, 2008), the Court evaluated a denial of benefits by MetLife based upon a subjective condition two year limitation.  Under the policy,

Monthly benefits are limited to 24 months during your lifetime if you are Disabled due to a:. . . .

2. Neuromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder to the spine or extremities and their surrounding soft tissue; including sprains and strains of joints and adjacent muscles, unless the Disability has objective evidence of

a. seropositive arthritis;

b. Spinal tumors, malignancy, or vascular malformations;

c. radiculopathies;

d. myelopathies;

e. traumatic spinal cord necrosis; or

f. musculopathies.

In essence, MetLife denied the claim on the basis that the Plaintiff did not have objective evidence of radiculopathies.  In great detail, the Court reviewed the medical evidence and concluded that MetLife arbitrarily afforded greater weight to its consultant’s opinion who never examined the plaintiff.  The Court further concluded that the Plaintiff was entitled to LTD benefits under the Plan because the medical evidence revealed post surgical nerve diseases.  And finally, the Court ruled that MetLife’s conduct was culpable such that prejudgment interest and attorney fees were appropriate.

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LTD Attorney Fees

In Cockrell v. Hartford Life and Accident Insurance Company, 2013 U.S.Dist. Lexis 69017 (W.D.Tenn. May 15, 2013), the Court decided a dispute between the parties concerning LTD attorney fees.  After succeeding on the merits with her LTD claim in District Court, the Plaintiff filed a Motion for Attorney’s Fees.  The defendant insurance company opposed the Motion.  First, the Court noted that as a preliminary matter, the plaintiff must have had “some degree of success on the merits.”  This threshold requirement is satisfied if the plaintiff obtains a remand.  Or, as stated by the court, “had received another shot at benefits by winning a remand.”  After determining the threshold issue, the Court examined the five factor test from Schwartz v. Gregori, 160 F.3d 116, 119 (6th Cir. 1998).  The five factors include:

  1. Culpability or bad faith
  2. Ability to Satisfy Award
  3. Deterrent effect
  4. Common benefit
  5. Merits of the case

After analyzing the five factors, the Court held: “the circumstances of this case favors an attorney’s fee award. . . .”

Next, the Court evaluating the reasonableness of the award.  Plaintiff claimed attorney fees of $23,725, which was supported by Affidavits from the plaintiff’s attorney, and another attorney located in Memphis.  The Court noted that “the lodestar approach is the proper method for calculating the award. When using the lodestar approach, ‘in which the number of hours reasonably expended on litigation is multiplied by a reasonable hourly rate,’ . . . . there is a strong presumption that the lodestar figure represents a reasonable fee.”  The Hartford challenged the figure by arguing that the number of hours litigating the case was unreasonable.  The Court carefully scrutinized the hours spent by plaintiff’s counsel, and reduced the figure to $21,225.00.

Attorney Fees for Long Term Disability ERISA cases

“In an action by [an ERISA] plan participant, the district court, in its discretion, ‘may allow a reasonable attorney’s fee and costs of action to either party.’ ” Moon v. Unum Provident Corp., 461 F.3d 639, 642 (6th Cir. 2006)

“[O]ur circuit recognizes no presumption as to whether  attorney fees will be awarded.” Foltice v. Guardsman Prods., Inc., 98 F.3d 933, 936 (6th Cir. 1996)

The Sixth Circuit applies a five-factor test to determine awarding fees:

(1) the degree of the opposing party’s culpability or bad faith; (2) the opposing party’s ability to satisfy an award of attorney’s fees; (3) the deterrent effect of an award on other persons under similar circumstances; (4) whether the party requesting fees sought to confer a common benefit on all participants and beneficiaries of an ERISA plan or resolve significant legal questions regarding ERISA; and (5) the relative merits of the parties’ positions.

“No single factor is determinative, and thus, the district court must consider each factor before exercising its discretion.” Id. at 642, 643.