If you are facing a long-term disability (LTD) denial from your insurance company, you’re not alone. Insurers frequently deny valid claims, forcing claimants into a long and frustrating appeals process. Fortunately, federal courts sometimes step in to hold them accountable.
A recent case, Dime v. Metropolitan Life Insurance Company, No. C24-0827-JCC (W.D. Wash. Jan. 29, 2025), is a perfect example of how can courts apply ERISA protections to ensure claimants receive the benefits they deserve. If you’re struggling with a denied LTD claim, this case could provide insight into how an ERISA disability lawyer can help you fight back.
Case Summary
The plaintiff worked as a Director of Administration for a wealth management firm. In 2023, she developed severe chronic pain that made it impossible to work. Her condition required frequent rest periods, and she was unable to sit for prolonged periods—an essential part of her job.
She applied for long-term disability benefits through her employer’s insurance provider, Metropolitan Life Insurance Company (MetLife), which administers the benefits under an ERISA-governed plan.
Despite strong medical evidence supporting her disability, MetLife denied her claim. The insurer argued that she could still perform her job with a sit/stand desk, despite clear evidence that her pain prevented her from sitting or standing for the required duration.
After exhausting MetLife’s internal appeals process, Dime took her case to federal court.
The Court’s Holding: MetLife Wrongfully Denied LTD Benefits
After reviewing the case de novo, the United States District Court for the Western District of Washington ruled in favor of Dime, finding that MetLife wrongfully denied her LTD benefits.
The court made several critical findings:
1. The Court Gave Signficant Weight to Dime’s Treating Physician’s Opinion
One of the key issues in the case was the weight given to Dime’s treating physician, Dr. Penny Li, who had been managing her condition for several years.
Dr. Li repeatedly documented that:
- Dime could not sit for more than 30 minutes at a time without needing to lie down for at least an hour to recover.
- She could not stand for more than 20 minutes at a time before experiencing severe pain.
- Even with an adjustable sit/stand desk, she could not work a full-time schedule due to her pain.
MetLife disregarded Dr. Li’s findings and relied instead on independent physician consultants (IPCs) who never examined Dime in person. These IPCs concluded that she was capable of working, despite overwhelming evidence to the contrary.
The court rejected MetLife’s selective reliance on its hired experts and instead gave significant weight to Dr. Li’s findings, noting that she had been treating Dime since 2020 and had firsthand knowledge of her condition.
2. The Ninth Circuit’s Bright-Line Rule on Sedentary Work Applied
Another key legal issue in the case was whether Dime could perform her job, which MetLife classified as “sedentary work.” Under Ninth Circuit law, an employee who cannot sit for more than four hours in an eight-hour workday cannot perform sedentary work.
This Ninth Circuit established this bright-line rule in Armani v. Northwestern Mutual Life Insurance Co., where the court ruled that an individual who cannot sit for at least half the workday cannot meet the definition of sedentary work.
In Dime’s case:
- MetLife’s own reviewing physician admitted that she could only sit for up to four hours per day—which is the absolute minimum for sedentary work.
- However, Dr. Li’s evaluation indicated that Dime could not even sit for four hours total in a workday, as she required long breaks to lie down.
- The court ruled that Dime was disabled under the Ninth Circuit’s standard and that MetLife’s decision violated established ERISA case law.
3. MetLife Ignored Critical Evidence Supporting Disability
MetLife’s denial was based largely on purported independent medical reviewers who never examined Dime in person and who are not independent in that they are paid (directly or indirectly) by the insurer. The court found that MetLife:
- Cherry-picked evidence that supported denial while ignoring strong medical documentation confirming Dime’s disability.
- Dismissed Dr. Li’s opinion despite her long treatment history with Dime.
- Overlooked statements from Dime’s employer, which confirmed that her job required extensive sitting—more than she was capable of.
Ultimately, the court ruled that Dime was disabled under the terms of the LTD policy and ordered MetLife to pay her benefits.
Why This Case Matters for LTD Claimants
If you’re dealing with an ERISA disability claim denial, this case provides several important takeaways:
1. Your Treating Physician’s Opinion Matters
- Insurance companies frequently rely on hired medical consultants to justify denials. However, the courts sometimes give more weight to the doctor who has been treating you over time—especially if their records are consistent and well-documented.
- At a minimum, your physician must support your disability claim through your medical records and, sometimes, a clear and detailed narrative explanation as to why you are disabled.
- If your healthcare provider does not support your disability claim, you can assume that the insurer’s consultants will not support it either.
2. The Ability to Sit for At Least Four Hours Per Day Is Crucial Sedentary Occupations
- If your insurance company claims you can do sedentary work, challenge them on this point.
- If you cannot sit for at least four hours per workday, Ninth Circuit law says you are disabled and entitled to LTD benefits.
- If you cannot sit for at least six hours out an eight-hour day, many courts have determined that you cannot perform sedentary work.
3. Insurance Companies Will Look for Any Reason to Deny Your Claim
- Even if you have strong medical evidence, insurers may cherry-pick records, downplay symptoms, or ignore key reports.
- Often your medical records and the opinions of your healthcare providers may be taken out of context or misrepresented to justify an ERISA disability claim denial.
- If your claim is denied, an experienced ERISA lawyer can help you fight back.
- Your ERISA disability appeal is a critical time to engage an attorney and build a detailed record to support your long-term disability claim.
What to Do If Your LTD Claim Is Denied
If your long-term disability claim has been denied, don’t give up. Insurance companies frequently deny valid claims in hopes that claimants will walk away. But as this case shows, you have the right to challenge an unfair denial—and win.
At The Garner Firm, Ltd. we devote a significant portion of our practice to handling ERISA disability cases and know how to take on big insurance companies like MetLife. If you’re struggling with a disability claim denial, we can help you fight for the benefits you deserve.
📞 Call us today for a free consultation!
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