Your Money Lost; MetLife’s Long-Term Disability Scam in MetLife v Glenn

We write a lot here about group long term disability policies and what bogus products they are. So much so, it is financially unsound to trust these policies to take care of you should you become injured, sick or disabled.

A particularly egregious example of just how worthless group policies are is seen in a case that made it to the Supreme Court (please note how the dissents fall in strict Citizen’s United lines) in Metropolitan Life Insurance Company v Glenn where MetLife was both the insurer and administrator of the group plan that insured Ms. Glenn–a huge conflict of interest. It’s like having the fox watch the hen house.

The plan grants MetLife (as administrator) discretionary authority to determine whether an employee’s claim for benefits is valid; it simultaneously provides that MetLife (as insurer) will itself pay valid benefit claims. App. 181a–182a.

MetLife sought Supreme Court review because of an earlier decision that forced MetLife to pay Ms. Glenn her benefits. MetLife spent a lot of money on this because of the precedent it set: An insurance company had to make good on a long-term disability claim and pay benefits to a person who became too disabled to work full time.

Ms. Glenn was a Sears employee who was diagnosed with severe dilated cardiomyopathy. She had dutifully paid her premiums and now she needed to use her benefits since she was too sick to work due to heart failure.

Respondent Wanda Glenn, a Sears employee, was diagnosed with severe dilated cardiomyopathy, a heart condition whose symptoms include fatigue and shortness of breath. She applied for plan disability benefits in June 2000, and MetLife concluded that she met the plan’s standard for an initial 24 months of benefits, namely, that she could not “perform the material duties of [her] own job.” Id., at 159a–160a. MetLife also directed Glenn to a law firm that would assist her in applying for federal Social Security disability benefits (some of which MetLife itself would be entitled to receive as an offset to the more generous plan benefits).

MetLife directed Ms. Glenn to a law firm to make sure she got Social Security so they could off-set her benefits. CIGNA and all the other insurers do the same. See my earlier blog postings at Illness and Insurance Hell. Just follow the money.

MetLife received the bulk of those retroactive benefits due to offsets written into the language of the policies themselves. These group disability policies are, in essence, bogus products; don’t waste your money.

The Social Security Administration consequently granted Glenn permanent disability payments retroactive to April 2000. Glenn herself kept none of the backdated benefits: three-quarters went to MetLife, and the rest (plus some additional money) went to the lawyers.

After the first two years of Ms. Glenn’s policy, MetLife decided to reverse themselves:

To continue receiving Sears plan disability benefits after 24 months, Glenn had to meet a stricter, Social-Security-type standard, namely, that her medical condition rendered her incapable of performing not only her own job but of performing “the material duties of any gainful occupation for which” she was “reasonably qualified.” App. 160a. MetLife denied Glenn this extended benefit because it found that she was “capable of performing full time sedentary work.” Id., at 31a.

On one hand, MetLife forced Ms. Glenn to apply for Social Security benefits, sent her to a law firm to help receive them and took taxpayer dollars to offset the plan she paid premiums for BUT when it came time to continue paying those benefits after the first two years, MetLife “itself had to determine whether she could work, in order to establish eligibility for extended plan benefits, it found her capable of doing sedentary work and denied her the benefits.”

This was what the Social Security agency said as well, but with help from the law firm they sent Ms. Glenn to, MetLife pushed, and received, tax payer dollars in the form of Social Security dollars. They burden the Social Security system.

The Supreme Court found this questionable as well and said so:

In particular, the court found questionable the fact that MetLife had encouraged Glenn to argue to the Social Security Administration that she could do no work, received the bulk of the benefits of her success in doing so (the remainder going to the lawyers it recommended), and then ignored the agency’s finding in concluding that Glenn could in fact do sedentary work. See id., at 666–669. This course of events was not only an important factor in its own right (because it suggested procedural unreasonableness), but also would have justified the court in giving more weight to the conflict (because MetLife’s seemingly inconsistent positions were both financially advantageous). And the court furthermore observed that MetLife had emphasized a certain medical report that favored a denial of benefits, had deemphasized certain other reports that suggested a contrary conclusion, and had failed to provide its independent vocational and medical experts with all of the relevant evidence. See id., at 669–674. All these serious concerns, taken together with some degree of conflicting interests on MetLife’s part, led the court to set aside MetLife’s discretionary decision.

MetLife also did the same thing CIGNA did to us, namely pick out information that bolstered their point of view of the reality of my husband’s disease, Multiple Sclerosis:

The Court of Appeals ultimately set aside MetLife’s denial of benefits in light of a combination of several circumstances…(3) MetLife’s focus upon one treating physician report suggesting that Glenn could work in other jobs at the expense of other, more detailed treating physician reports indicating that she could not; (4) MetLife’s failure to provide all of the treating physician reports to its own hired experts; and (5) MetLife’s failure to take account of evidence indicating that stress aggravated Glenn’s condition. See id., at 674.

If you are wondering why this happens, it’s simply due to corporate greed and money–lots of money. These group policies are huge money makers for the large health insurance companies and they rake in billions in profits each year from them. Paying out claims to people with Multiple Sclerosis is not what they want to do–their interests lie in fattening the bottom line.

As financial tools, they are worthless and a waste of your hard-earned dollars. You have alternatives such as private policies. Save your money and look elsewhere. And if you think these policies need to be better regulated or ERISA should be removed or rewritten as law, write your members of Congress. That’s what we pay them for.

Your health and well-being do not matter to large corporate entities no matter how much they try to spin it otherwise. See AHIP.

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Your Money Lost: Group Long Term Disability Insurance Policies

Did you know your tax dollars are used to subsidize private health insurance companies?

If you are unfamiliar with Social Security Disability Insurance, here is an excellent primer put out by AARP. SSDI provides protection specifically to qualified U.S. citizens who become disabled and lose their ability to earn an income. We all pay for this through our Social Security taxes. It’s one of the many benefits of being a United States citizen.

When my husband was employed at Fidelity Investments he had a group disability insurance policy with CIGNA. He even purchased extra coverage–to protect our family with 80% of Paul’s income just in case something happened.

But that money was ill-spent as CIGNA did everything in their power to deny coverage to a man with Progressive-Relapsing Multiple Sclerosis. This is not unusual behavior for any private insurance company. In fact, it’s exactly what they do.

But first, you must apply for Social Security Disability Insurance.

When Paul was mid-way through with short term disability and it appeared he was getting progressively worse and not better, CIGNA telephoned us to inform us that they were getting his file ready for long term disability. Great, we thought, they are helping us! Isn’t that what they collect a premium each month for? The answer to that is, no. They collect a premium each month to make money. Keeping that money and not paying it out in claims helps their bottom line.

From the Group Life Market Survey 2009 outlining the sales in disability insurance, you can see group sales disability totaled $1.3 billion at mid-year, with 27 private insurance companies covering 95% of the total market.

After CIGNA denied Paul’s benefits, they telephoned us again. “You must apply for Social Security benefits and send us proof of your application or your long term application with us will be invalid.”

Why does a private insurance corporation demand that you apply for government benefits?

Money, that’s why. If you qualify and receive Social Security Disability Insurance then your insurance company will off-set the amount of money they contractually owe you by the amount of money you will receive from the government. For example, if Paul’s CIGNA policy was to have paid him $5,000 a month and SSDI would give him $2,000 a month, then CIGNA would subtract that amount and only give Paul $3,000 a month. Your tax dollars are used to subsidize private corporations.

Your money is used to fatten the bottom lines of Aetna, AIG Benefit Solutions (that’s how much now in government money for AIG?) CIGNA, Guardian Life, Hartford Life, Mutual of Omaha, Northwest Mutual, Prudential, Sun Life, UnitedHealthcare, Unum and Wellpoint, to name but a few.

Why pay a premium at all?

An entire industry has been set-up surrounding group disability plans to help private insurers NOT pay the claim.

For example, every year the American Conference Institute (one among many) has a yearly event titled, “Litigating Disability Insurance Claims.” Please click the link and read the brochure–it is so very eye-opening. From the brochure, here is what the insurance companies, their general counsels, federal judges (they are the very same federal judges who will decide your disability case!) and doctors will discuss at the above-mentioned conference, emphasis in blue is mine:

    • Whether the medical record is reliable: Whether the treating physician is biased and favors the patient
    • Providing the credentials of the IME’s (Independent Medical Examiner–hired by insurance company): Identifying what is relevant; Highlighting the appropriate credentials; Ways to appropriately critique the credentials of the IME: what to look for and ways to address the inadequacies; Whether specialized medical knowledge is a necessary component of the IME’s credentials (in the case of Multiple Sclerosis, patients are seen and treated by neurologists, the IME who looked at Paul’s written medical records was not a neurologist and first letter of denial was written by an RN and not a doctor)
    • Rotating vendors to avoid the appearance of bias and to ensure an independent review of the claim
    • The denial factor: How many claims were reviewed and denied?; Whether repetitive denial leads to an appearance of bias; Ways to utilize claim denial information
    • Whether the claimant is constrained by financial pressures and returns to work disabled

The last one is of particular interest to me because that is exactly what happened to this family. This family, faced with zero income as Paul had been the sole bread winner for most of our married lives, had to return to work at Fidelity Investments, disabled. This is something the insurance company counts on to help bolster their claim that you are not disabled.

Medical evidence that you are disabled will not prevail.

This conference, and others like it, focus on how to prevent paying a claim, and it does not matter if the claim is legitimate, what matters is the corporate bottom line. The American Conference Institute also has another conference dedicated to defending ERISA claims attended by more federal judges–the very same ones who will hear your ERISA disability case.

Your premium dollars, the ones you work so very hard to pay each month to your private insurance carrier, are not spent on paying a claim should you wake up one day with cancer, MS or become injured in an accident. No. Those hard earned dollars are spent on figuring out how not to pay you. And then, they use your tax dollars to reduce the amount they owe you.

United States taxpayers, it’s time to say enough. Group long-term disability policies are bogus products. They should either be highly regulated or not allowed to be sold at all, as the poorly written policies and the attendant machines put in place by the insurance companies to deny all claims, make the products fraudulent and worthless.

Links:

CIGNA written brochure for brokers about their long term disability product.

Dell and Schaefer, a law firm, discussing CIGNA including the LINA settlement in California.

The 11 Federal Judges Attending the 2011 Defending and Managing ERISA Litigation Conference.

The American Conference Institute assembles a yearly “defending against ERISA claims” conference usually held in New York City. This year’s conference is at the New York Marriott Downtown.

If you have Multiple Sclerosis or any other disease that forced you to fight for your benefits because companies like CIGNA lied (not hyperbole) to prevent your claim, then you know all about ERISA or the Employment and Retirement Income Security Act of 1974. Unfortunately, ERISA has had negative consequences. A full explanation, written by an ERISA expert, can be found here.

But you may not know that the very same federal judges who may hear your case attend these conferences where they help coach insurance companies, plan providers and other attorneys on how to defend against ERISA claims. In other words, how to make sure a company like CIGNA doesn’t have to fulfill their contractual obligations and pay your claim. From the conference brochure:

An ERISA Moot Court: Featuring top defense attorneys arguing some of the hottest and most common issues facing ERISA practitioners today, panels of renowned ERISA jurists will critique arguments, question our litigators and help all attendees understand how to successfully convey their positions to the court.

The federal judges, the ones deciding your cases, are going to going to participate in a moot court to help defend against ERISA claims? How does that square with remaining impartial as part of the judges’s code of conduct? And our favorite here at the MS Activism Foundation:

Breaking Up Is Hard to Do: A Focus on Severance Plan Litigation including Triggering Events, COBRA Hang-Ups, and the Other Litigation Issues that Arise in Separation Situations.

CIGNA had a big loss this year in CIGNA v. Amara, even though they are spinning it otherwise, so of course, CIGNA’s senior counsel, Christina McNally will be in attendance at the conference.

Fidelity Investments, my husband’s former employer, is listed on the last page as being in attendance as well. I could not find a name though. Last year it was their very own senior counsel, (and Paul’s fellow Boston College alum) Laura Tholen.

Here are the names and districts of all the federal judges who are attending this year’s conference. And here is a link to the PDF of the 2011 conference. If you are fighting for your claim, and see your judge, send them a letter. Tell them that you know what they’re doing and that it certainly does not appear impartial.

Here are the Codes of Conduct for United States Judges and be sure to ask about CANON 3: A JUDGE SHOULD PERFORM THE DUTIES OF THE OFFICE FAIRLY, IMPARTIALLY AND DILIGENTLY.

Hon. Daniel E. Knowles, III U.S. Dist. Ct., E.D. La.

Hon. Morton Denlow U.S. Dist. Ct., N.D. Ill.

Hon. Matthew Kennelly U.S. Dist. Ct., N.D. Ill.

Hon. William S. Duffey, Jr. U.S. Dist. Ct., N.D. Ga.

Hon. Viktor Pohorelsky U.S. Dist. Ct., E.D.N.Y.

Fernando J. Gaitan, Jr. U.S. Dist. Ct., W.D. Mo.

Hon. Timothy C. Batten, Sr.U.S. Dist. Ct., N.D. Ga.

Hon. Robert Jonker U.S. Dist. Ct., W.D. Mo. (I think the American Conference Institute meant MI not MO.)

Hon. Richard G. Stearns U.S. Dist. Ct., D. Mass.

Hon. John Coughenour U.S. Dist. Ct., W.D. Wash.

Hon. Robert B. Collings U.S. Dist. Ct., D. Mass.

Bits and Pieces; Updates on Campath/Lemtrada, Health Care Reform and the National MS Society.

If you have been following this blog because you or a family member has Multiple Sclerosis you may know about the Sanofi takeover of Genzyme. Alternately, if you are one the many pharmaceuticals or investors or PR and advertising firms that visit us, you already do know that Sanofi completed the $20.1 billion buyout of Genzyme.

Which brings us to Campath (acquired from Bayer by Genzyme) now known, or trying to be known, as Lemtrada. We have written about it here because of the shameful desire to increase the price of a relatively inexpensive cancer treatment to $60,000 per year for Multiple Sclerosis treatment.

It is NOT YET APPROVED for use by the FDA. Campath/Lemtrada is still in clinical trials. Here is a link to the latest in their Clinical Trials.

At one point, Genzyme was giving Campath away for compassionate use in cancer patients. This was done by Genzyme to erase the yearly sales figures so that when the same drug rolls out (when approved) the $60,000 per year price sticker for Multiple Sclerosis won’t have a sales comparison number–of something much, much cheaper. Redefines the whole meaning of compassion, doesn’t it?

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Health Care Reform:

While the Affordable Care Act is not yet a law–we still have until 2014 for the whole thing to go into effect–the GOP is back to using their favorite catch phrase, “death panels.”

Here is a link to an article in Talking Points Memo about Rep. Phil Gingrey (R-GA) raising the dirty spectre of death panels and rationing yet again. Just an FYI, Rep. Gingrey voted to abolish Medicare. I think the good doctor should know better than to espouse what he does, but here’s the quote:

“[U]nder this IPAB we described that the Democrats put in Obamacare, where a bunch of bureaucrats decide whether you get care, such as continuing on dialysis or cancer chemotherapy, I guarantee you when you withdraw that the patient is going to die,” Gingrey said. “It’s rationing.”

We’re the only democratic and industrialized nation in the world without a universal plan; a plan where anyone can buy into a risk pool and get themselves covered no matter what. We all get sick, it’s part of the human condition. It’s how we treat ourselves that defines our society.

My husband now, having been without insurance for six months, can finally apply to the new high risk pool–thanks to the Affordable Care Act. We ask the representative from Georgia, “What should we do, Dr. Gingrey?” Repeal the health care law like you and every member of the GOP want to do so that my husband (and all other Americans like him) will go without health insurance and health care?

Crying tort reform over and over, as Dr. Gingrey does, isn’t going to fix the system, but considering that the good doctor has himself been sued for malpractice several times, it becomes obvious why he repeats this so often. And why he’s introduced legislation into Congress that would limit damages for pain and suffering from malpractice cases. See H.R. 5 of the 112th Congress.

Dr. Gingrey has this to say about health care reform:

“Just one year has elapsed since the government takeover of our healthcare system and Obamacare has done nothing but create hardships for Americans and place burdens on businesses,” said Congressman Phil Gingrey. “Since its passage, state budgets have been crushed by rising Medicaid costs, businesses have struggled to keep their doors open due to onerous new administrative and tax burdens, and American citizens are being threatened with rising costs and less access to quality care. As we move forward in pursuit of a full repeal of Obamacare, we must stay committed to replacing it with meaningful, cost-cutting reforms that will improve health care, lower costs, and put Americans back to work.”

Government takeover of health care? A proven lie.

If government is so bad, why does Dr. Gingrey want to use government to sharply cut medical malpractice awards? Won’t the free market just sort things out on its own?

But if Dr. Gingrey is speaking about the government creation of a high risk pool to help my husband and all Americans with pre-existing conditions get access to health care by purchasing insurance that will cover them, then I suggest he re-read his Hippocratic Oath.

As for tax burdens and small businesses, small businesses love the Affordable Care Act because they get tax breaks. And read more here, from Fox News.

Are we being threatened by rising costs? Yes. Why? Because Dr. Gingrey and his GOP ilk refuse to expand Medicare to Everyone. A national health plan that would compete for customers may inspire the private health insurers to actually produce a good product. Competition does that. As it is now, the private health insurers have zero competition.

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Now onto the National Multiple Sclerosis Society:

We got a flyer from the National MS Society the other day about their teleconference series that, “is designed to support individuals with MS through the continuum of their work experiences; from staying employed, to retraining and on to post-employment options. Understanding how to access vital resources will help individuals make the best choices through any stage of their workforce journey.”

With all the money the National MS Society takes in (and spends), this piece of writing just sent me over the edge as it purports to say something without saying anything at all. They paid for that with your donation dollars. And it gets worse:

Applying Through Your Employer’s Long Term Disability Benefits When MS Progresses

Featured speaker Lisa Kantor, LLP from Kantor and Kantor will share her expertise as an advocate who has successfully represented people in Employment Retirement Income Security Act (ERISA) benefit claims for over 18 years. If you have MS and Long Term Disability Insurance through your employer, you will want to know how to apply for and access these vital benefits.

Let me just begin by saying that the whole reason I’m here writing this, the whole reason this Foundation exists is because of the way my husband was treated both by his Long Term Disability insurance carrier, CIGNA.

He was denied his benefits by CIGNA. Twice. We had no where to turn for help, including the MS Society at the time.

This sort of teleconference series makes the National MS Society look good, but doesn’t really help. And with all the money they have, imagine what they could do. They could start by lobbying Congress to fix ERISA–that would go a long way in helping not just those with MS but all who have been denied their benefits or who have been mistreated by their health insurer.

Listening to Ms. Kantor may be helpful, she may even gain a few clients from this teleconference, but she can’t help you “apply for and access these vital benefits.” She simply cannot and that has nothing to do with Ms. Kantor.

See, one cannot actually access their long term disability benefits. I wrote extensively about that over at Illness and Insurance Hell.

Your insurance carrier starts the process while you are still on short-term disability; they will insist you apply for Social Security benefits and prove that you have been through that process or else they’ll deny your claim. They will even offer you help with one of their attorneys to make sure you go through the Social Security process.

To make matters even worse, they will obfuscate the truth (that’s called lying) in the face of medical evidence; they make things up. And when they are threatened with legal action, they send photographers (bad ones I’d like to add) to your house to photograph you and your family. My husband has lesions on his brain and spinal cord, could the guy with the camera, snapping away at us, somehow disprove that?

Then, after all of that, they all attend conferences with federal judges (among others) to figure out how to defend against ERISA claims. Anything not to pay a claim.

Which brings me back to the Affordable Care Act, the Ryan plan to abolish Medicare and the GOP still trying to get rid of health care reform.

I ask this: If the GOP succeeds in repealing health care (doubtful) but say they do, then the provisions in the law that help people, that stop lifetime caps, give seniors free preventative care, that fill the Medicare donut hole, that stops insurers from retroactively cancelling your plan, that gives Medicare drug discounts–if the GOP stops all this then what good is that $8,000 Ryan Voucher?

The GOP using states’ rights to repeal health care reform. What about ERISA?

The GOP loves big business more than they care about those constituents who elect them. Even thought the GOP uses states’ rights as a big rallying cry for repealing health care reform, they have been totally against amending the federal law that strips the states of their rights–when it comes to health insurance.

Let me explain.

ERISA laws or the Employee Retirement Income Security Act of 1974 set standards for pension plans so that when employees retired (and retire even though 401k plans have replaced most pension plans) they can breathe some sigh of relief that their employers did not raid their pension plans leaving them penniless for retirement. That’s one of the things it does, but it does a lot of other things as well. It covers employer-based health insurance plans, 401k plans and some severance plans.

The unintended consequences of having a federal law cover these things, especially health benefits, are that these federal laws pre-empt state laws.

The law limits the abilities of state legislatures to regulate many types of health insurance, it restricts the kinds of remedies that states can authorize (such as a patient’s right to independent appeal of denials or to see specialists) and it can limit the ability of states to experiment with novel ideas for health care solutions.

Two real-life examples of how our state laws and consumer protections are meaningless if we have been abused by our health insurers: The first one is in the Michael Moore movie, Sicko, and features a child named Annette Noe. This is also brought up in Wendell Potter’s book, Deadly Spin. Annette needed cochlear implants in both her ears but CIGNA only paid for one, calling implants in both ears, “too experimental.”

Think Progress featured another child in November of last year, Madison Leuchtmann, who CIGNA also refused to pay for her cochlear implants with the knowledge that this child may remain deaf the rest of her life if she did not receive the implants:

Unfortunately, the Leuchtmann’s family insurer, Cigna, has issued “one denial after another,” flatly refusing to cover the $20,000 bill for the implant. In a written statement to the local news station Fox 2, Cigna explained, “It is not unusual for commercial benefit plans to exclude hearing assisted devices,” prompting Dr. Clary to angrily respond, “This is obviously medically necessary. You have a child that has no ear canals!” Dr. Clary also told Fox 2 that he sees these sort of denials “on a weekly basis.” Watch Fox 2′s report:

Now in Annette Noe’s case, her father used the power of Michael Moore’s movie to get Annette her implants. I have no follow up news for Madison. But more importantly here, could Madison’s parents sue CIGNA to make them pay for her implants? The answer is no. And that’s because of ERISA.

And why is that? Let’s turn to an ERISA expert, an attorney, Richard Johnston and his blog, The Problem is ERISA:

As of now we have a situation where the law tells insurers they face no meaningful consequences if they deny care improperly or even commit outright fraud. As one federal judge has commented, “if an HMO wrongly denies a participant’s claim even in bad faith, the greatest cost it could face is being compelled to cover the procedure, the very cost it would have faced had it acted in good faith. Any rational HMO will recognize that if it acts in good faith, it will pay for far more procedures than if it acts otherwise, and punitive damages, which might otherwise guard against such profiteering, are no obstacle at all.” Insurance companies, of course, are not charities, but corporations; their boards are subject to a fiduciary duty to maximize shareholder value. If it is possible to accomplish this by mistreating insureds, then it follows insurers will do precisely that (and believe me, they do).

There is no incentive, financially speaking, to pay for benefits and these include treatments, transplants and disability benefits that are all covered under the ERISA umbrella.

Where does that leave the GOP who are so “anti-big government but pro-states’ rights? They side with those who would keep these laws in tact every time: The Health Insurance Industry. Disturbing about both groups is their love of thumbing their noses to the new (unconstitutional, as they say) federal law while remaining steadfast on guarding another federal law that hurts the common good. I guess it’s only unconstitutional when it hurts the corporate common good.

Every time ERISA has come up in Congress for some tweaking, guess what has happened? AHIP hires lobbyists, front groups (like this National Coalition on Benefits, they are a real gem) and this group; they all go into action and We, the People, are left in serfdom at the corrupt feet of the Insurance Lords.