MetLife Insurance Claim Denied? How to Appeal and Win

MetLife serves over 90 million customers across more than 40 countries and dominates the U.S. group benefits market — providing employer-sponsored life, dental, disability, vision, and accident insurance to millions of American workers. When MetLife denies your claim, the reason and your appeal path depend heavily on whether your coverage is an employer-sponsored group plan governed by ERISA or an individual policy governed by state insurance law. Either way, the denial is not final.

Why MetLife Denies Insurance Claims

MetLife's denial patterns vary by product line but follow identifiable structures.

Group life insurance denials. Death during the 2-year contestability period triggers MetLife's review of the application for material misrepresentation. Other common denials include failure to satisfy the eligibility waiting period before death, evidence of insurability (EOI) not obtained for supplemental coverage above the guaranteed issue amount, late enrollment without a qualifying life event, and cause of death falling under a policy exclusion such as the suicide clause within the first two years.

Dental claim denials. MetLife dental denials frequently involve the missing tooth clause (replacement of teeth absent before coverage effective date), frequency limitations on restorations, plan maximum already reached, Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization not obtained for major services, or the service determined not to be covered under the applicable dental benefit schedule.

Disability claim denials. MetLife LTD denials involve insufficient medical documentation, paper-only medical reviews contradicting treating physicians, the own-occupation to any-occupation definition transition at 24 months (29 CFR § 2560.503-1), pre-existing condition exclusions, FCE results used to assert sedentary work capacity, and surveillance evidence alleged to contradict claimed limitations.

Accident and critical illness denials. These voluntary benefit denials typically involve the insurer arguing the event does not meet the policy's definition of a covered accident or critical illness, or that a pre-existing condition exclusion applies.

How to Appeal

Step 1: Review the Denial Letter and Identify the Governing Law

Read MetLife's denial letter to identify the specific reason, the policy provision cited, and your appeal deadline. Determine whether your coverage is governed by ERISA (most employer-sponsored plans) or state insurance law (individual policies). ERISA plans are governed by 29 CFR § 2560.503-1 and provide a 180-day internal appeal window for disability claims. ACA-compliant health and dental plans are governed by 45 CFR § 147.136. Individual policies are governed by state law, which varies by state.

Step 2: Request Your Complete Claims File

Under ERISA (29 CFR § 2560.503-1(h)(2)(iii)), you have the right to request all documents, records, and other information relevant to your claim at no charge. For non-ERISA plans, request the complete file under your state's insurance regulations. The file often reveals weaknesses in MetLife's denial rationale that you can directly address in your appeal.

Step 3: Gather Supporting Documentation for Your Claim Type

For disability claims, obtain detailed treating physician narrative reports, objective diagnostic results, and independent expert opinions. For life insurance contestability denials, gather the original application, death certificate, medical records, and evidence that any application inaccuracy was unintentional and immaterial. For dental claims, obtain the treating dentist's narrative justification for the procedure and clinical records supporting the diagnosis. For each claim type, specifically address MetLife's stated denial reason with targeted evidence.

Step 4: Write Your Internal Appeal Letter

Your appeal letter should reference your policy number, claim number, and the date of MetLife's denial; quote the denial reason verbatim; address each reason with specific evidence referencing attached exhibits by number; cite applicable regulations; and state a specific requested outcome. For ERISA plans, cite 29 CFR § 2560.503-1 and MetLife's obligation to conduct a full and fair review. MetLife must respond within 45 days for disability claims (29 CFR § 2560.503-1(i)), 30 days for pre-service health claims, and 60 days for post-service health claims.

Step 5: Obtain Independent Evidence

For disability claims, MetLife frequently relies on paper reviews. Counter these with an independent medical examination by a specialist who has actually examined you. For life insurance contestability denials, submit evidence that any application inaccuracy was unintentional and not material to the risk. Courts consistently find that treating physician opinions based on personal examination outweigh paper reviewer opinions.

Step 6: Escalate to External Independent Review: Complete Guide" class="auto-link">External Review or Litigation

For health and dental claims: request external review under ACA Section 2719 (42 U.S.C. § 300gg-19) within 4 months of the final internal denial. For disability and life insurance ERISA claims: file suit in federal court under ERISA Section 502(a)(1)(B). For individual non-ERISA policies: file a complaint with your state department of insurance and pursue state-law remedies, which may include bad faith claims. File with the DOL's EBSA at dol.gov/agencies/ebsa for ERISA violations.

What to Include in Your Appeal

• MetLife denial letter with each denial reason identified and addressed point-by-point
• Supporting documentation specific to your claim type: treating physician reports (disability), death certificate and application documentation (life), dentist narrative (dental)
• Independent expert opinions if MetLife relied on paper reviews or in-house vocational analyses
• Citations to 29 CFR § 2560.503-1 and 29 U.S.C. § 1133 for ERISA plans; 45 CFR § 147.136 for ACA health/dental plans; state insurance code for individual policies

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